Basic Information
| Provider Information | |||||||||
| NPI: | 1972695047 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINNACLE HEALTH HOSPITALS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PINNACLE HEALTH HOSPITALS MILESTONES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8700 | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171058700 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171102058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177823131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 07/26/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LONGENDERFER | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7172308200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1000025630096 | 01 | PA | CBHNP | OTHER | 1000025630096 | 01 | PA | CCBHO | OTHER | 1000025630096 | 05 | PA | MEDICAID |