Basic Information
Provider Information | |||||||||
NPI: | 1831164227 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE MILTON S. HERSHEY MEDICAL CENTER PHYSICIAN GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MSHMC REPRODUCTIVE ENDOCRINOLOGY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 858 | ||||||||
Address2: | MCA410 | ||||||||
City: | HERSHEY | ||||||||
State: | PA | ||||||||
PostalCode: | 170330858 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002431455 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 500 UNIVERSITY DR | ||||||||
Address2: |   | ||||||||
City: | HERSHEY | ||||||||
State: | PA | ||||||||
PostalCode: | 170332360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002431455 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2006 | ||||||||
LastUpdateDate: | 04/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MASSINI | ||||||||
AuthorizedOfficialFirstName: | STEVE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7175318405 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VE0102X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Reproductive Endocrinology |
ID Information
ID | Type | State | Issuer | Description | 1007452910073 | 05 | PA |   | MEDICAID |