Provider Demographics
NPI:1205838919
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 (REHABILITATION ONLY)
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT AND CEO
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:570-621-5111
Mailing Address - Street 1:700 E NORWEGIAN ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-2710
Mailing Address - Country:US
Mailing Address - Phone:570-621-4765
Mailing Address - Fax:570-621-4769
Practice Address - Street 1:700 E NORWEGIAN ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2710
Practice Address - Country:US
Practice Address - Phone:570-621-4765
Practice Address - Fax:570-621-4769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA590201273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1613OtherHIGHMARK BLUE SHIELD
PA39T031Medicare ID - Type Unspecified