Provider Demographics
NPI:1174118566
Name:PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:TINCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-531-1788
Mailing Address - Street 1:PO BOX 848
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0848
Mailing Address - Country:US
Mailing Address - Phone:610-208-8818
Mailing Address - Fax:717-531-0119
Practice Address - Street 1:1540 ALEXANDRA LN
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-3656
Practice Address - Country:US
Practice Address - Phone:717-798-3363
Practice Address - Fax:717-798-3364
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN STATE HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-08
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty