Provider Demographics
NPI:1003935354
Name:MIFFLIN COUNTY COMMUNITY SURGICAL CENTER PC
Entity Type:Organization
Organization Name:MIFFLIN COUNTY COMMUNITY SURGICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-242-2514
Mailing Address - Street 1:27 SANDY LN STE 220
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17044-1320
Mailing Address - Country:US
Mailing Address - Phone:717-242-4805
Mailing Address - Fax:717-242-5900
Practice Address - Street 1:311 4TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-1316
Practice Address - Country:US
Practice Address - Phone:717-242-9565
Practice Address - Fax:717-242-9510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA10611500-PII261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017198290003Medicaid
PA390822OtherCAPITAL BLUE CROSS
PA1751OtherHIGHMARK BLUE SHIELD
PA018426Medicare ID - Type Unspecified