Basic Information
| Provider Information | |||||||||
| NPI: | 1881899896 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLOOMSBURG PHYSICIANS SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BLOOMSBURG INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 549 FAIR ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178151419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703872249 | ||||||||
| FaxNumber: | 5703872327 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 E 1ST ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178151480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703872249 | ||||||||
| FaxNumber: | 5703872327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 02/29/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EICHERT | ||||||||
| AuthorizedOfficialFirstName: | EILEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5703872249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02279900 | 01 | PA | CBC | OTHER |