Healthcare Provider Details

I. General information

NPI: 1417019498
Provider Name (Legal Business Name): JERSEY SHORE HOSPITAL FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 EAST CENTRAL AVENUE
AVIS PA
17721
US

IV. Provider business mailing address

104 EAST CENTRAL AVENUE PO BOX 430
AVIS PA
17721
US

V. Phone/Fax

Practice location:
  • Phone: 570-753-8620
  • Fax: 570-753-5489
Mailing address:
  • Phone: 570-753-8620
  • Fax: 570-753-5489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CAREY W. PLUMMER
Title or Position: CEO
Credential: CEO
Phone: 570-398-3101