Provider Demographics
NPI:1679756993
Name:EVANGELICAL MEDICAL SERVICES ORGANIZATION
Entity Type:Organization
Organization Name:EVANGELICAL MEDICAL SERVICES ORGANIZATION
Other - Org Name:EMSO EVAN FAMILY MEDICINE LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:AUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-522-2807
Mailing Address - Street 1:130 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9315
Mailing Address - Country:US
Mailing Address - Phone:570-522-4134
Mailing Address - Fax:570-522-4120
Practice Address - Street 1:3 HOSPITAL DR
Practice Address - Street 2:SUITE 214
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-9362
Practice Address - Country:US
Practice Address - Phone:570-524-4242
Practice Address - Fax:570-524-2130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007498260005Medicaid