NPIMap

Organization Active NPI

Schuylkill Medical Center - South Jackson Street

Doing business as Schuylkill Medical Center - South Jackson Street Psychiatry Group

  • Psychiatry Physician
  • Pottsville, PA
National Provider Identifier
1982606802
Registry record updated Jul 16, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET
Doing business as
Schuylkill Medical Center - South Jackson Street Psychiatry Group
Practice address
420 S Jackson St
Pottsville, PA 17901-3625
Phone
(570) 621-5000
Fax
(570) 622-8221
NPI assigned
Aug 11, 2005
Last updated
Jul 16, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 16, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John E. Simodejka
Title
President and Ceo
Phone
(570) 621-5111

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2084P0800X Primary

Addresses

Primary practice location

420 S Jackson St
Pottsville, PA 17901-3625

Mailing address

420 S Jackson St
Pottsville, PA 17901-3625
Phone (570) 621-5000

Other names 1

  • Schuylkill Medical Center - South Jackson Street Psychiatry Group Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040408001006 PA Part B Supplier - Hospital Department(S) 4183525959 Practice locations: Pottsbille, PA; Pottsville, PA

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1123718400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1373932800000",
    "number": "1982606802",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "420 S JACKSON ST",
            "city": "POTTSVILLE",
            "state": "PA",
            "postal_code": "179013625",
            "telephone_number": "570-621-5000",
            "fax_number": "570-622-8221"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "420 S JACKSON ST",
            "city": "POTTSVILLE",
            "state": "PA",
            "postal_code": "179013625",
            "telephone_number": "570-621-5000",
            "fax_number": "570-622-8221"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SCHUYLKILL MEDICAL CENTER - SOUTH JACKSON STREET",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-11",
        "last_updated": "2013-07-16",
        "status": "A",
        "authorized_official_last_name": "SIMODEJKA",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "E.",
        "authorized_official_title_or_position": "PRESIDENT AND CEO",
        "authorized_official_telephone_number": "570-621-5111"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Schuylkill Medical Center - South Jackson Street Psychiatry Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Pottsville, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.