1063168409 NPI number — PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC

Table of content: (NPI 1063168409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063168409 NPI number — PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1063168409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 848
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERSHEY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17033-0848
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-208-8818
Provider Business Mailing Address Fax Number:
717-312-3104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 CENTER ST STE 1A110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMP HILL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17011-1741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-775-5093
Provider Business Practice Location Address Fax Number:
717-775-5094
Provider Enumeration Date:
02/24/2022

Additional Information

Authorized Official

Authorized Official Last Name:
YUSKOVIC
Authorized Official First Name:
MARGARET
Authorized Official Middle Name:
Authorized Official Title or Position:
DELEGATED
Authorized Official Telephone Number:
610-208-8818

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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