Provider Demographics
NPI:1336486356
Name:PEQUEA VALLEY COMMUNITY MEDICINE
Entity Type:Organization
Organization Name:PEQUEA VALLEY COMMUNITY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:R
Authorized Official - Last Name:LACORTE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:717-442-9505
Mailing Address - Street 1:836 HOUSTON RUN DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GAP
Mailing Address - State:PA
Mailing Address - Zip Code:17527-9496
Mailing Address - Country:US
Mailing Address - Phone:717-442-9505
Mailing Address - Fax:717-442-9531
Practice Address - Street 1:836 HOUSTON RUN DR
Practice Address - Street 2:SUITE 201
Practice Address - City:GAP
Practice Address - State:PA
Practice Address - Zip Code:17527-9496
Practice Address - Country:US
Practice Address - Phone:717-442-9505
Practice Address - Fax:717-442-9531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG55562Medicare UPIN