Basic Information
| Provider Information | |||||||||
| NPI: | 1205098829 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINNACLE HEALTH MEDICAL SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PPI MEDICAL COVERAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 7177826420 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2008 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARKLEY | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP | ||||||||
| AuthorizedOfficialTelephone: | 7172318210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007666760064 | 05 | PA | MEDICAID | 029490 | 01 | PA | MEDICARE GROUP PROVIDER | OTHER |