=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669715660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PA RTE 120 INPATIENT SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2013
-----------------------------------------------------
Last Update Date | 07/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 PINE ST
-----------------------------------------------------
City | RENOVO
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17764-1618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-923-1000
-----------------------------------------------------
Fax | 570-923-1189
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 37928
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19101-0528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-355-0808
-----------------------------------------------------
Fax | 610-834-2862
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE VICE PRESIDENT
-----------------------------------------------------
Name | JOSEPH W. TAYLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-444-7009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------