Basic Information
| Provider Information | |||||||||
| NPI: | 1982740510 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE MILTON S HERSHEY MEDICAL CENTER PHYSICIANS GROUP | ||||||||
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| OtherOrganizationName: | MSHMC GOOD DRIVE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 858 | ||||||||
| Address2: | MC A410 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170330858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175311159 | ||||||||
| FaxNumber: | 7175317269 | ||||||||
| Practice Location | |||||||||
| Address1: | 694 GOOD DR | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176012433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175443754 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 04/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | MASSINI | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7175318405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 135101 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207VM0101X | 135101 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007452910088 | 05 | PA | MEDICAID |