Healthcare Provider Details

I. General information

NPI: 1104851849
Provider Name (Legal Business Name): DIVINE PROVIDENCE HOSPITAL OF THE SISTERS OF CHRISTIAN CHARITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1909
US

IV. Provider business mailing address

1205 GRAMPIAN BLVD 2ND FLOOR
WILLIAMSPORT PA
17701-1978
US

V. Phone/Fax

Practice location:
  • Phone: 570-326-8000
  • Fax: 570-326-8601
Mailing address:
  • Phone: 570-326-8676
  • Fax: 570-326-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number041001
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number041001
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number041001
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number041001
License Number StatePA

VIII. Authorized Official

Name: MR. ERIC D. POHJALA
Title or Position: EXECUTIVE VICE PRESIDENT CFO, CPO
Credential: FHFMA, FACHE
Phone: 570-321-3171