Provider Demographics
NPI:1164726733
Name:CARBON-SCHUYLKILL COMMUNITY HOSPITAL, INC.
Entity Type:Organization
Organization Name:CARBON-SCHUYLKILL COMMUNITY HOSPITAL, INC.
Other - Org Name:ST. LUKE'S MINER'S PHYSICIAN ASSISTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHTENWALNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-954-3301
Mailing Address - Street 1:360 W RUDDLE ST
Mailing Address - Street 2:
Mailing Address - City:COALDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18218-1027
Mailing Address - Country:US
Mailing Address - Phone:570-645-2131
Mailing Address - Fax:
Practice Address - Street 1:360 W RUDDLE ST
Practice Address - Street 2:
Practice Address - City:COALDALE
Practice Address - State:PA
Practice Address - Zip Code:18218-1027
Practice Address - Country:US
Practice Address - Phone:570-645-2131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA178775Medicare PIN