Provider Demographics
NPI:1457824013
Name:PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EX. VICE PRES, CHIEF FINANCIAL OFC
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-531-6614
Mailing Address - Street 1:4520 UNION DEPOSIT RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-2910
Mailing Address - Country:US
Mailing Address - Phone:717-909-4139
Mailing Address - Fax:
Practice Address - Street 1:4520 UNION DEPOSIT RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-2910
Practice Address - Country:US
Practice Address - Phone:717-909-4139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-07
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty