=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750564076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVANGELICAL MEDICAL SERVICES ORGANIZATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2007
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 N 5TH ST
-----------------------------------------------------
City | LEWISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17837-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-523-3350
-----------------------------------------------------
Fax | 570-522-0404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 HOSPITAL DR
-----------------------------------------------------
City | LEWISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17837-9315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-522-4134
-----------------------------------------------------
Fax | 570-522-4120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MRS. KENDRA A. AUCKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-522-2807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------