Basic Information
| Provider Information | |||||||||
| NPI: | 1952897738 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | PENN STATE HEALTH MEDICAL GROUP - SCHUYLKILL VALLEY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 HOPE DR | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170332036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175311159 | ||||||||
| FaxNumber: | 7175310119 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 S CENTRE AVE | ||||||||
| Address2: | |||||||||
| City: | LEESPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109265707 | ||||||||
| FaxNumber: | 6109268352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2018 | ||||||||
| LastUpdateDate: | 08/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | MASSINI | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT, CFO | ||||||||
| AuthorizedOfficialTelephone: | 7175316614 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.