Provider Demographics
NPI:1073816690
Name:PENN STATE HERSHEY ENDOSCOPY CENTER LLC
Entity Type:Organization
Organization Name:PENN STATE HERSHEY ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-272-4481
Mailing Address - Street 1:32 COLONNADE WAY
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-2309
Mailing Address - Country:US
Mailing Address - Phone:814-272-4481
Mailing Address - Fax:814-272-4470
Practice Address - Street 1:32 COLONNADE WAY
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2309
Practice Address - Country:US
Practice Address - Phone:814-272-4481
Practice Address - Fax:814-272-4470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2287I501261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA39C0001291OtherMEDICARE CCN