Provider Demographics
NPI:1538610431
Name:GOOD SHEPHERD PENN PARTNERS PENN SPECIALTY HOSPITAL
Entity type:Organization
Organization Name:GOOD SHEPHERD PENN PARTNERS PENN SPECIALTY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP FINANCE AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:PETULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-776-3228
Mailing Address - Street 1:1800 LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1414
Mailing Address - Country:US
Mailing Address - Phone:877-969-7342
Mailing Address - Fax:
Practice Address - Street 1:20 E 11TH AVE
Practice Address - Street 2:
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-1555
Practice Address - Country:US
Practice Address - Phone:610-828-7505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA22460101261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center