Provider Demographics
NPI:1952897738
Name:PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Other - Org Name:PENN STATE HEALTH MEDICAL GROUP - SCHUYLKILL VALLEY
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT, CFO
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 1:90 HOPE DR
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2036
Mailing Address - Country:US
Mailing Address - Phone:717-531-1159
Mailing Address - Fax:717-531-0119
Practice Address - Street 1:5 S CENTRE AVE
Practice Address - Street 2:
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533
Practice Address - Country:US
Practice Address - Phone:610-926-5707
Practice Address - Fax:610-926-8352
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-05
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty