Provider Demographics
NPI:1003032558
Name:GOOD SHEPHERD CORPORATION
Entity Type:Organization
Organization Name:GOOD SHEPHERD CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTOGNOLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-702-8360
Mailing Address - Street 1:1327 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2861
Mailing Address - Country:US
Mailing Address - Phone:570-702-8360
Mailing Address - Fax:570-702-8623
Practice Address - Street 1:1327 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18509-2861
Practice Address - Country:US
Practice Address - Phone:570-702-8360
Practice Address - Fax:570-702-8623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAXRC970900251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007283070005Medicaid