Healthcare Provider Details

I. General information

NPI: 1497398564
Provider Name (Legal Business Name): GSLPG VASCULAR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PARAMOUNT BLVD
ORWIGSBURG PA
17961-2202
US

IV. Provider business mailing address

801 OSTRUM ST
BETHLEHEM PA
18015-1000
US

V. Phone/Fax

Practice location:
  • Phone: 272-639-1000
  • Fax:
Mailing address:
  • Phone: 484-526-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN CHIAVAROLI
Title or Position: CVO SUPERVISOR
Credential:
Phone: 484-526-3569