Provider Demographics
NPI:1447233424
Name:PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES
Entity Type:Organization
Organization Name:PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES
Other - Org Name:CLARKS SUMMIT STATE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-772-2518
Mailing Address - Street 1:1451 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-9504
Mailing Address - Country:US
Mailing Address - Phone:570-587-7250
Mailing Address - Fax:570-587-7415
Practice Address - Street 1:1451 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-9504
Practice Address - Country:US
Practice Address - Phone:570-587-7250
Practice Address - Fax:570-587-7415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100308518Medicaid
PA394012Medicare Oscar/Certification
PA100308518Medicaid
PACN0736Medicare PIN