Provider Demographics
NPI:1073710166
Name:SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET
Entity Type:Organization
Organization Name:SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET
Other - Org Name:GOOD SAMARITAN REGIONAL MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SIMODEJKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-621-5111
Mailing Address - Street 1:700 E NORWEGIAN ST
Mailing Address - Street 2:PHYSICAN BILLING
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-2710
Mailing Address - Country:US
Mailing Address - Phone:570-621-8646
Mailing Address - Fax:570-621-4316
Practice Address - Street 1:700 E NORWEGIAN ST
Practice Address - Street 2:PHYSICAN BILLING
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2710
Practice Address - Country:US
Practice Address - Phone:570-621-8646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCHUYLKILL MEDICAL CENTER - EAST NORWEGIAN STREET
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-02
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA363A00000X, 363AS0400X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1783963OtherHIGHMARK BS
PA018633Medicare PIN
PA018633Medicare ID - Type Unspecified