Basic Information
| Provider Information | |||||||||
| NPI: | 1205269891 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPIRIT PHYSICIAN SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOLY SPIRIT BEHAVIORAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 GRANDVIEW AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | CAMP HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170111708 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 503 N 21ST ST | ||||||||
| Address2: | |||||||||
| City: | CAMP HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170112204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177632100 | ||||||||
| FaxNumber: | 7179724470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2013 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | GATESMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| 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 | 101YM0800X | MD033364E | PA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 2084P0802X | MD033364E | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry |
No ID Information.