Basic Information
| Provider Information | |||||||||
| NPI: | 1891394441 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CRYSTAL A DR | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170339524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175311159 | ||||||||
| FaxNumber: | 7175310119 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 CENTER ST STE 1A110 | ||||||||
| Address2: | |||||||||
| City: | CAMP HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170111702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177755093 | ||||||||
| FaxNumber: | 7177755094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2020 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | TINCH | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5859221223 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.