Provider Demographics
NPI:1598351405
Name:KIDSPEACE CHILDREN'S HOSPITAL, INC.
Entity Type:Organization
Organization Name:KIDSPEACE CHILDREN'S HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-799-7517
Mailing Address - Street 1:4085 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:SCHNECKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18078-2574
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 4TH ST STE 5
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1869
Practice Address - Country:US
Practice Address - Phone:570-253-7910
Practice Address - Fax:570-253-7985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100728370-0043Medicaid