Healthcare Provider Details

I. General information

NPI: 1609390483
Provider Name (Legal Business Name): GROVE CITY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 08/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 N BROAD STREET EXT
GROVE CITY PA
16127-4603
US

IV. Provider business mailing address

631 N. BROAD STREET EXT.
GROVE CITY PA
16127-4603
US

V. Phone/Fax

Practice location:
  • Phone: 724-450-7000
  • Fax: 724-450-7013
Mailing address:
  • Phone: 724-450-7000
  • Fax: 724-450-7013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberOS005324L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberOS005324L
License Number StatePA

VIII. Authorized Official

Name: MR. ROBERT C JACKSON JR.
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 724-450-7197