Basic Information
| Provider Information | |||||||||
| NPI: | 1770824617 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THER MILTON S. HERSHEY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | OUTPATIENT PSYCH CLINIC - NOLL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170332360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002431455 | ||||||||
| FaxNumber: | 7174351010 | ||||||||
| Practice Location | |||||||||
| Address1: | 2170 NOLL DR | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176037609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7174351000 | ||||||||
| FaxNumber: | 7174351010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2013 | ||||||||
| LastUpdateDate: | 03/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | HALEY | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7175318521 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 327730 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.