Provider Demographics
NPI:1306989967
Name:JERSEY SHORE HOSPITAL
Entity type:Organization
Organization Name:JERSEY SHORE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-398-3100
Mailing Address - Street 1:1020 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:JERSEY SHORE
Mailing Address - State:PA
Mailing Address - Zip Code:17740-1729
Mailing Address - Country:US
Mailing Address - Phone:570-398-0100
Mailing Address - Fax:570-398-4412
Practice Address - Street 1:1020 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:JERSEY SHORE
Practice Address - State:PA
Practice Address - Zip Code:17740-1729
Practice Address - Country:US
Practice Address - Phone:570-398-0100
Practice Address - Fax:570-398-4412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101401133V00000X, 2085R0202X, 282NC0060X, 363AS0400X, 367500000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No282NC0060XHospitalsGeneral Acute Care HospitalCritical AccessGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA222070OtherRADIOLOGY FPH
PA391300OtherWORKERS COMP
PA1007703560004Medicaid
PA230275OtherHA RADIOLOGY
PA3634OtherGHP
PAC10719OtherRR MEDICARE DR GROUP
PA116482OtherHA ER
PA139690OtherHA ANESTHSIA
PA222069OtherER FPH
PA057613Medicare ID - Type UnspecifiedPHYSICIAN GROUP