Basic Information
| Provider Information | |||||||||
| NPI: | 1922771534 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PSHMG - SURGERY/SPECIALTY SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848 | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170330848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175311159 | ||||||||
| FaxNumber: | 4848782169 | ||||||||
| Practice Location | |||||||||
| Address1: | 890 POPLAR CHURCH RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | CAMP HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170112250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177617244 | ||||||||
| FaxNumber: | 7177612055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2021 | ||||||||
| LastUpdateDate: | 02/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | YUSKOVIC | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED | ||||||||
| AuthorizedOfficialTelephone: | 6102088818 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN STATE HEALTH | ||||||||
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| NPICertificationDate: | 02/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RB0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Bariatric Medicine | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 208200000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | 2086S0120X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086S0127X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086X0206X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 208C00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.