Healthcare Provider Details

I. General information

NPI: 1235137472
Provider Name (Legal Business Name): JEWISH HOME OF EASTERN PENNSYLVANIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 VINE ST
SCRANTON PA
18510-2126
US

IV. Provider business mailing address

1101 VINE ST
SCRANTON PA
18510-2126
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-6177
  • Fax: 570-344-9610
Mailing address:
  • Phone: 570-344-6177
  • Fax: 570-344-9610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number360402
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number360402
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number360402
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0007472840001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: SAMUEL K SANDHAUS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 570-344-6177