Provider Demographics
NPI:1134114119
Name:EVANGELICAL AMBULATORY SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:EVANGELICAL AMBULATORY SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:MALONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-524-6700
Mailing Address - Street 1:210 JPM RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9367
Mailing Address - Country:US
Mailing Address - Phone:570-524-6700
Mailing Address - Fax:570-524-6710
Practice Address - Street 1:210 JPM RD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-9367
Practice Address - Country:US
Practice Address - Phone:570-524-6700
Practice Address - Fax:570-524-6710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA14631501261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007755680001Medicaid
PA20025739OtherAMERIHEALTH PROVIDER NUMB
PA39C0001119OtherSTERLING OPTION I
PA79197OtherGEISINGER HEALTH PLAN
PA0167726OtherDEPARTMENT OF LABOR PROV#
PA155458XXOtherPREFERRED CARE
PA151805OtherHEALTH AMERICA PROV#
PA390839OtherCAPITAL BLUE CROSS
PA1599OtherHIGHMARK BLUESHIELD
PA490005320OtherRAILROAD MEDICARE
PA39C0001119OtherSTERLING OPTION I