Basic Information
| Provider Information | |||||||||
| NPI: | 1871548560 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIVINE PROVIDENCE HOSPITAL OF THE SISTERS OF CHRISTIAN CHARITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SUSQUEHANNA HOME CARE & HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1100 GRAMPIAN BLVD | ||||||||
| Address2: | 4 SOUTH | ||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177011909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703207690 | ||||||||
| FaxNumber: | 5703207692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 GRAMPIAN BLVD | ||||||||
| Address2: | 4 SOUTH | ||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177011909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703207690 | ||||||||
| FaxNumber: | 5703207692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 01/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGEE | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5703207690 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 700605 | PA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1007563750023 | 05 | PA | MEDICAID | 817415 | 01 | PA | FPH BILLING NUMBER | OTHER |