Provider Demographics
NPI:1144217738
Name:MENNO HAVEN INC
Entity Type:Organization
Organization Name:MENNO HAVEN INC
Other - Org Name:MENNO HAVEN PHYSICIAN SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-262-1000
Mailing Address - Street 1:1425 PHILADELPHIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-1386
Mailing Address - Country:US
Mailing Address - Phone:717-261-4194
Mailing Address - Fax:717-261-4319
Practice Address - Street 1:1425 PHILADELPHIA AVE
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1386
Practice Address - Country:US
Practice Address - Phone:717-261-4194
Practice Address - Fax:717-261-4319
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MENNO HAVEN INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-29
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA665949Medicare ID - Type UnspecifiedGROUP NUMBER