Provider Demographics
NPI:1417019498
Name:JERSEY SHORE HOSPITAL FOUNDATION, INC
Entity Type:Organization
Organization Name:JERSEY SHORE HOSPITAL FOUNDATION, INC
Other - Org Name:JERSEY SHORE MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:PLUMMER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:570-398-3101
Mailing Address - Street 1:104 EAST CENTRAL AVENUE
Mailing Address - Street 2:PO BOX 430
Mailing Address - City:AVIS
Mailing Address - State:PA
Mailing Address - Zip Code:17721
Mailing Address - Country:US
Mailing Address - Phone:570-753-8620
Mailing Address - Fax:570-753-5489
Practice Address - Street 1:104 EAST CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:AVIS
Practice Address - State:PA
Practice Address - Zip Code:17721
Practice Address - Country:US
Practice Address - Phone:570-753-8620
Practice Address - Fax:570-753-5489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACL3010OtherRAILROAD MEDICARE
PA1001557500008Medicaid
PA220807OtherFIRST PRIORITY HEALTH
PA5938OtherAETNA
PAC2CEOtherGEISINGER HEALTH PLAN
PA555630OtherBLUE CROSS BLUE SHIELD
PA5938OtherAETNA