Provider Demographics
NPI:1568536480
Name:GOOD SHEPHERD REHABILITATION HOSPITAL
Entity Type:Organization
Organization Name:GOOD SHEPHERD REHABILITATION HOSPITAL
Other - Org Name:GOOD SHEPHERD REHAB HOSPITAL DEPARTMENT OF PSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE - CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETULLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-776-3303
Mailing Address - Street 1:850 S 5TH ST
Mailing Address - Street 2:GOOD SHEPHERD PLAZA
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-3308
Mailing Address - Country:US
Mailing Address - Phone:610-776-3214
Mailing Address - Fax:610-776-3506
Practice Address - Street 1:850 S 5TH ST
Practice Address - Street 2:GOOD SHEPHERD PLAZA
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-3308
Practice Address - Country:US
Practice Address - Phone:610-776-3214
Practice Address - Fax:610-776-3506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA027899Medicare PIN