Provider Demographics
NPI:1184787731
Name:BON SECOURS COMMUNITY HOSPITAL
Entity type:Organization
Organization Name:BON SECOURS COMMUNITY HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN SERVICES-CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LYDDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-987-3954
Mailing Address - Street 1:510 ROUTE 6 AND 209
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-7615
Mailing Address - Country:US
Mailing Address - Phone:570-296-5950
Mailing Address - Fax:570-296-1066
Practice Address - Street 1:510 ROUTE 6 AND 209
Practice Address - Street 2:SUITE 8
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337-7615
Practice Address - Country:US
Practice Address - Phone:570-296-5950
Practice Address - Fax:570-296-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA057872Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
NYW60431Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER