Provider Demographics
NPI:1417059619
Name:PINE GROVE INTERNAL MEDICINE, INC.
Entity Type:Organization
Organization Name:PINE GROVE INTERNAL MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACOBUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-741-5600
Mailing Address - Street 1:1938 SECURITY DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-4727
Mailing Address - Country:US
Mailing Address - Phone:717-741-5600
Mailing Address - Fax:717-741-6750
Practice Address - Street 1:1938 SECURITY DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-4727
Practice Address - Country:US
Practice Address - Phone:717-741-5600
Practice Address - Fax:717-741-6750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034489E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty