Provider Demographics
NPI:1598930638
Name:MOUNT NITTANY MEDICAL CENTER
Entity Type:Organization
Organization Name:MOUNT NITTANY MEDICAL CENTER
Other - Org Name:CENTER FOR WOUND CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-234-6148
Mailing Address - Street 1:120 RADNOR RD
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7970
Mailing Address - Country:US
Mailing Address - Phone:814-231-7868
Mailing Address - Fax:814-238-4169
Practice Address - Street 1:120 RADNOR RD
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7970
Practice Address - Country:US
Practice Address - Phone:814-231-7868
Practice Address - Fax:814-238-4169
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNT NITTANY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-29
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA550301282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007466550003Medicaid
390268OtherMEDICARE PROVIDER #