Basic Information
| Provider Information | |||||||||
| NPI: | 1104404441 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 UNIVERSITY DRIVE | ||||||||
| Address2: | MAILCODE CA410 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170332360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175311159 | ||||||||
| FaxNumber: | 7175310119 | ||||||||
| Practice Location | |||||||||
| Address1: | 1819 S. MARKET STREET | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176919683 | ||||||||
| FaxNumber: | 7176919689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2021 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | TINCH | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7175311788 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN STATE HEALTH | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.