Basic Information
| Provider Information | |||||||||
| NPI: | 1225243884 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHOENIXVILLE HOSPITAL COMPANY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHOENIXVILLE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 504060 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631500001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109831000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 140 NUTT RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIXVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194603906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109831000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEWSOME | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT GROUP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6154657000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 420901 | PA | X | Ambulatory Health Care Facilities | Clinic/Center | 261QA1903X | 420901 | PA | X | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1010953150002 | 05 | PA | MEDICAID |