Basic Information
Provider Information | |||||||||
NPI: | 1982228185 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE MILTON S. HERSHEY MEDICAL CENTER PHYSICIAN GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 858 | ||||||||
Address2: |   | ||||||||
City: | HERSHEY | ||||||||
State: | PA | ||||||||
PostalCode: | 170330858 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175315814 | ||||||||
FaxNumber: | 7175310494 | ||||||||
Practice Location | |||||||||
Address1: | 500 UNIVERSITY DR STE 400 | ||||||||
Address2: |   | ||||||||
City: | HERSHEY | ||||||||
State: | PA | ||||||||
PostalCode: | 170332360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175316822 | ||||||||
FaxNumber: | 7175314907 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2020 | ||||||||
LastUpdateDate: | 06/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HITZ | ||||||||
AuthorizedOfficialFirstName: | BRENDA | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 7175315995 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MILTON S HERSHEY MEDICAL CENTER PHYSICIANS GROUP | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |   |
No ID Information.