MEDICARE: QITA ASC-HARRISBURG, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2085R0204X	Vascular & Interventional Radiology Physician
2	261QR0200X	Radiology Clinic/Center
3	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1588291686
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QITA ASC-HARRISBURG, LLC

Provider Business Mailing Address
First Line	:	815 SIR THOMAS CT
Second Line	:
City	:	HARRISBURG
State	:	PA
Zip	:	17109-4839
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	815 SIR THOMAS CT
Second Line	:
City	:	HARRISBURG
State	:	PA
Zip	:	17109-4839
Country	:	US
Telephone Number	:	717-938-2765
Fax Number	:

Authorized Official
Title or Position	:	CHIEF PRODUCT & STRATEGY OFFICER
Name	:	MR. BENJAMIN SLATER
Credential	:
Telephone Number	:	717-932-6343

Provider Enumeration Date	:	03/26/2020
Last Update Date	:	03/26/2020

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Directions to “QITA ASC-HARRISBURG, LLC ” Practice Location

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