Basic Information
| Provider Information | |||||||||
| NPI: | 1760430342 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE MILTON S. HERSHEY MEDICAL CENTER PHYSICIANS GROUP | ||||||||
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| OtherOrganizationName: | MSHMC MEDICAL NUTRITIONAL THERAPY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 854 | ||||||||
| Address2: | MC A410 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170330854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175315995 | ||||||||
| FaxNumber: | 7175316934 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 SCHOOLHOUSE RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170573548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179485180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HALEY | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7175318810 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1007452910081 | 05 | PA | MEDICAID |