Provider Demographics
NPI:1033394564
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:DIVINE PROVIDENCE HOSPITAL
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VP CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:SANTANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:CPA FHFMA
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 1:471 HEPBURN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6122
Practice Address - Country:US
Practice Address - Phone:570-567-5400
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:2008-01-03
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA041001261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007563750029Medicaid