Provider Demographics
NPI:1104851849
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 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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA041001261QA1903X, 261QR0206X, 282N00000X, 283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA20012697OtherAMERIHEALTH HMO AMER PIN
PA816867OtherFIRST PRIORITY HEALTH PIN
PA000070OtherAMERIHEALTH ADMINST PIN
PA394048OtherHEALTH ASSURANCE PIN
PA1066310OtherKEYSTONE MERCY HEALTH PIN
PA396871OtherBLACK LUNG PROGRAM PIN
PA1007563750008Medicaid
PA394048OtherBLUE CROSS PIN
PA394048OtherAETNA PIN
PA70159OtherGEISINGER HEALTH PLAN PIN
PA394048OtherHEALTH AMERICA PIN
PA1066310OtherKEYSTONE MERCY HEALTH PIN
PA394048OtherHEALTH AMERICA PIN