Provider Demographics
NPI:1710958251
Name:MOUNT NITTANY MEDICAL CENTER
Entity Type:Organization
Organization Name:MOUNT NITTANY MEDICAL CENTER
Other - Org Name:MENTAL HEALTH UNIT
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 1:1800 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-6701
Mailing Address - Country:US
Mailing Address - Phone:814-231-7000
Mailing Address - Fax:
Practice Address - Street 1:1800 E PARK AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6701
Practice Address - Country:US
Practice Address - Phone:814-231-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNT NITTANY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-01
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA39S268273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA39S268Medicare ID - Type UnspecifiedMENTAL HEALTH
PA435513Medicare PIN