Basic Information
| Provider Information | |||||||||
| NPI: | 1801433149 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | PENN STATE HEALTH MEDICAL GROUP - PULMONARY AND CRITICAL CARE MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848 | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170330848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102088818 | ||||||||
| FaxNumber: | 7173123104 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170431440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172342561 | ||||||||
| FaxNumber: | 7172361121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2019 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | YUSKOVIC | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
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| AuthorizedOfficialTitleorPosition: | DELEGATED | ||||||||
| AuthorizedOfficialTelephone: | 6102088818 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN STATE HEALTH COMMUNITY MEDICLA GROUP, LLC | ||||||||
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| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 2080P0214X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | 207RC0200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.