Basic Information
| Provider Information | |||||||||
| NPI: | 1063073823 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCHUYLKILL HEALTH SYSTEM MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LVPG EXPRESSCARE SCHUYLKILL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 783311 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191783311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844500 | ||||||||
| FaxNumber: | 4848840699 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SCHUYLKILL MEDICAL PLZ | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706219200 | ||||||||
| FaxNumber: | 5706219201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2019 | ||||||||
| LastUpdateDate: | 08/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | DEMOPOULOS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR VP & COO LVPG | ||||||||
| AuthorizedOfficialTelephone: | 4848623333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SCHUYLKILL HEALTH SYSTEM MEDICAL GROUP, INC. | ||||||||
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| NPICertificationDate: | 08/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.