Basic Information
Provider Information | |||||||||
NPI: | 1700154325 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE PENNSYLVANIA STATE UNIVERSITY COLLEGE OF MEDICINE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PENN STATE COLLEGE OF MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 UNIVERSITY DRIVE | ||||||||
Address2: |   | ||||||||
City: | HERSHEY | ||||||||
State: | PA | ||||||||
PostalCode: | 17003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175310003 | ||||||||
FaxNumber: | 7175315481 | ||||||||
Practice Location | |||||||||
Address1: | 500 UNIVERSITY DRIVE | ||||||||
Address2: |   | ||||||||
City: | HERSHEY | ||||||||
State: | PA | ||||||||
PostalCode: | 17003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175310003 | ||||||||
FaxNumber: | 7175315481 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/09/2011 | ||||||||
LastUpdateDate: | 12/09/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FALVO | ||||||||
AuthorizedOfficialFirstName: | VINCENT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOCIATE CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 7175317674 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | THE PENNSYLVANIA STATE UNIVERSITY | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
No ID Information.