Basic Information
Provider Information | |||||||||
NPI: | 1144369364 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PINNACLE HEALTH MEDICAL SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KLINE HEALTH CENTER NEUROLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1286 | ||||||||
Address2: |   | ||||||||
City: | HARRISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 171081286 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172318960 | ||||||||
FaxNumber: | 7172318964 | ||||||||
Practice Location | |||||||||
Address1: | 2501 N 3RD ST | ||||||||
Address2: |   | ||||||||
City: | HARRISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 171101904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172318960 | ||||||||
FaxNumber: | 7172318964 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOGENDERFER | ||||||||
AuthorizedOfficialFirstName: | ROGER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESEIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 7172318200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1007666760064 | 05 | PA |   | MEDICAID |