Provider Demographics
NPI:1629057039
Name:ST JOSEPHS INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:ST JOSEPHS INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:GURBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-339-2160
Mailing Address - Street 1:300 S HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:MT CARMEL
Mailing Address - State:PA
Mailing Address - Zip Code:17851
Mailing Address - Country:US
Mailing Address - Phone:570-339-2160
Mailing Address - Fax:570-339-4193
Practice Address - Street 1:300 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:MT CARMEL
Practice Address - State:PA
Practice Address - Zip Code:17851
Practice Address - Country:US
Practice Address - Phone:570-339-2160
Practice Address - Fax:570-339-4193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA01054599Medicaid
PADA2400OtherRAILROAD MEDICARE
PA02325000OtherBLUE CROSS
PA402980OtherBLUE SHIELD
C33440Medicare UPIN
PA02325000OtherBLUE CROSS