Basic Information
Provider Information | |||||||||
NPI: | 1245296029 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPIRIT PHYSICIAN SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOLY SPIRIT OB/GYN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 205 GRANDVIEW AVE | ||||||||
Address2: | SUITE 210 | ||||||||
City: | CAMP HILL | ||||||||
State: | PA | ||||||||
PostalCode: | 170111708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7179724480 | ||||||||
FaxNumber: | 7179724470 | ||||||||
Practice Location | |||||||||
Address1: | 423 N 21ST ST | ||||||||
Address2: |   | ||||||||
City: | CAMP HILL | ||||||||
State: | PA | ||||||||
PostalCode: | 170112201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7177639880 | ||||||||
FaxNumber: | 7177372765 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2006 | ||||||||
LastUpdateDate: | 10/05/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GATESMAN | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7179724480 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife |   | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207VG0400X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
No ID Information.