Basic Information
| Provider Information | |||||||||
| NPI: | 1114333952 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINNACLE HEALTH MEDICAL SERVICES | ||||||||
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| OtherOrganizationName: | PINNACLEHEALTH FASTCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 SOUTH SEOND STREET | ||||||||
| Address2: | SUITE 2F | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171041612 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3301 TRINDLE RD | ||||||||
| Address2: | |||||||||
| City: | CAMP HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170114413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7174127859 | ||||||||
| FaxNumber: | 7179653214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2014 | ||||||||
| LastUpdateDate: | 11/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | PUGH | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP | ||||||||
| AuthorizedOfficialTelephone: | 7172318245 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100766676 0064 | 05 | PA | MEDICAID |