Provider Demographics
NPI:1750373965
Name:PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
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 1:3912 TRINDLE RD
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-4246
Mailing Address - Country:US
Mailing Address - Phone:717-761-8740
Mailing Address - Fax:717-761-8792
Practice Address - Street 1:3912 TRINDLE RD
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-4246
Practice Address - Country:US
Practice Address - Phone:717-761-8740
Practice Address - Fax:717-761-8792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1750373965OtherMEDICARE NPI
PA0009855260006Medicaid
PA0009855260006Medicaid
PA412692Medicare PIN