Provider Demographics
NPI:1861576993
Name:DIVINE PROVIDENCE HOSPITAL OF THE SISTERS OF CHRISTIAN CHARITY
Entity type:Organization
Organization Name:DIVINE PROVIDENCE HOSPITAL OF THE SISTERS OF CHRISTIAN CHARITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT CFO, CPO
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:D
Authorized Official - Last Name:POHJALA
Authorized Official - Suffix:
Authorized Official - Credentials:FHFMA, FACHE
Authorized Official - Phone:570-321-3171
Mailing Address - Street 1:1205 GRAMPIAN BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1978
Mailing Address - Country:US
Mailing Address - Phone:570-326-8676
Mailing Address - Fax:570-326-8601
Practice Address - Street 1:1100 GRAMPIAN BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1909
Practice Address - Country:US
Practice Address - Phone:570-326-8000
Practice Address - Fax:570-326-8601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE PROVIDENCE HOSPITAL OF THE SISTERS OF CHRISTIAN CHARITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-25
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA041001261Q00000X, 261QR0206X, 283Q00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007563750014Medicaid
PA20012697OtherAMERIHEALTH HMO AMER PIN
PA396871OtherBLACK LUNG PROGRAM PIN
PA816867OtherFIRST PRIORITY HEALTH PIN
PA000070OtherAMERIHEALTH ADMINSTR PIN
PA1007563750031Medicaid
PA1007563750036Medicaid
PA394048OtherAETNA PIN
PA394048OtherHEALTH AMERICA PIN
PA1007563750034Medicaid
PA1007563750035Medicaid
PA70159OtherGEISINGER HEALTH PLAN PIN
PA1007563750033Medicaid
PA1066310OtherKEYSTONE MERCY HEALTH PIN
PA394048OtherBLUE CROSS PIN
PA394048OtherHEALTH ASSURANCE PIN
PA1007563750033Medicaid
PA1007563750036Medicaid