Basic Information
| Provider Information | |||||||||
| NPI: | 1174118566 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | PENN STATE HEALTH MEDICAL GROUP - BLUE RIDGE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848 | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170330848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102088818 | ||||||||
| FaxNumber: | 7175310119 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 ALEXANDRA LN | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171103656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177983363 | ||||||||
| FaxNumber: | 7177983364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2021 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | TINCH | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7175311788 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN STATE HEALTH | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.