Provider Demographics
NPI:1487001749
Name:GAUDENZIA
Entity Type:Organization
Organization Name:GAUDENZIA
Other - Org Name:GAUDENZIA LEWISBURG OUTPATIENT
Other - Org Type:Other Name
Authorized Official - Title/Position:SR. CONTRACTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-338-3731
Mailing Address - Street 1:106 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19401-4716
Mailing Address - Country:US
Mailing Address - Phone:610-239-9600
Mailing Address - Fax:610-275-7025
Practice Address - Street 1:480 HAFER RD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-7413
Practice Address - Country:US
Practice Address - Phone:570-524-3884
Practice Address - Fax:570-768-4779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA607058261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center