Basic Information
| Provider Information | |||||||||
| NPI: | 1861556193 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKVILLE HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PENN HIGHLANDS BROOKVILLE ANESTHESIOLOGISTS/CRNAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | BROOKVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158251367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148491439 | ||||||||
| FaxNumber: | 8148491493 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | BROOKVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158251367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148492312 | ||||||||
| FaxNumber: | 8148494841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PEER | ||||||||
| AuthorizedOfficialFirstName: | JULIANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8148491461 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN HIGHLANDS HEALTHCARE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | PA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1007733760004 | 05 | PA | MEDICAID | 015029 | 01 | PA | MC GROUP PTAN | OTHER |