Basic Information
| Provider Information | |||||||||
| NPI: | 1659337210 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNISTS OF CENTRAL PENNSYLVANIA LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 LOWTHER ST | ||||||||
| Address2: | |||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170432045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177741366 | ||||||||
| FaxNumber: | 7177744232 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 LOWTHER ST | ||||||||
| Address2: | |||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170432045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177741366 | ||||||||
| FaxNumber: | 7177744232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 07/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | TYNDALL MD | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SECR | ||||||||
| AuthorizedOfficialTelephone: | 7177741366 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0010307750020 | 05 | PA | MEDICAID |