Basic Information
| Provider Information | |||||||||
| NPI: | 1942955521 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENN STATE HEALH COMMUNITY MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848 | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170330848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102088818 | ||||||||
| FaxNumber: | 7173123104 | ||||||||
| Practice Location | |||||||||
| Address1: | 2494 BERNVILLE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196059467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103782996 | ||||||||
| FaxNumber: | 6102088812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2022 | ||||||||
| LastUpdateDate: | 02/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | YUSKOVIC | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
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| AuthorizedOfficialTitleorPosition: | DELEGATED | ||||||||
| AuthorizedOfficialTelephone: | 6102088818 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.