Basic Information
| Provider Information | |||||||||
| NPI: | 1063803641 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPIRIT PHYSICIAN SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WOUND CARE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 UNIVERSITY DRIVE | ||||||||
| Address2: | MAILCODE CA410 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170332036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175311159 | ||||||||
| FaxNumber: | 7175310119 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 N 21ST ST | ||||||||
| Address2: | |||||||||
| City: | CAMP HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170112204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177632100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2015 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | DILLON | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | EX VICE PRES & CHIEF CLINICAL OFC | ||||||||
| AuthorizedOfficialTelephone: | 7175318066 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.