Provider Demographics
NPI:1689119794
Name:DIAKON MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:DIAKON MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP/COO/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:D
Authorized Official - Last Name:HABECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-795-0384
Mailing Address - Street 1:1022 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17057-2158
Mailing Address - Country:US
Mailing Address - Phone:717-795-0384
Mailing Address - Fax:717-795-0353
Practice Address - Street 1:280 MIDDLE HOLLAND RD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:PA
Practice Address - Zip Code:18966-4822
Practice Address - Country:US
Practice Address - Phone:717-795-0457
Practice Address - Fax:717-796-6801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-28
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty