Provider Demographics
NPI:1861601098
Name:SUNBURY HOSPITAL CORPORATION
Entity type:Organization
Organization Name:SUNBURY HOSPITAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT GROUP OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7000
Mailing Address - Street 1:PO BOX 504236
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-0001
Mailing Address - Country:US
Mailing Address - Phone:570-286-3333
Mailing Address - Fax:
Practice Address - Street 1:350 N 11TH ST
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-1611
Practice Address - Country:US
Practice Address - Phone:570-286-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBURY HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-22
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA450302261Q00000X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101423612003Medicaid