Basic Information
| Provider Information | |||||||||
| NPI: | 1194183822 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPIRIT PHYSICIAN SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 GRANDVIEW AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | CAMP HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170111708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179724480 | ||||||||
| FaxNumber: | 7179724156 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 ERFORD RD | ||||||||
| Address2: | |||||||||
| City: | WORMLEYSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170431163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177633008 | ||||||||
| FaxNumber: | 7179726865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2016 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | GATESMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE -PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7179724480 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.