Basic Information
| Provider Information | |||||||||
| NPI: | 1700067782 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINNACLE HEALTH MEDICAL SERVICES | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | PINNACLE HEALTH FAMILY CARE OF HALIFAX | ||||||||
| 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: | 36 S RIVER RD | ||||||||
| Address2: | |||||||||
| City: | HALIFAX | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170328604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178963901 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 11/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | LONGENDERFER | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESEIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7172318200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007666760064 | 05 | PA | MEDICAID |