Provider Demographics
NPI:1104404441
Name:PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Other - Org Name:
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 1:500 UNIVERSITY DRIVE
Mailing Address - Street 2:MAILCODE CA410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2360
Mailing Address - Country:US
Mailing Address - Phone:717-531-1159
Mailing Address - Fax:717-531-0119
Practice Address - Street 1:1819 S. MARKET STREET
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055
Practice Address - Country:US
Practice Address - Phone:717-691-9683
Practice Address - Fax:717-691-9689
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN STATE HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty