MEDICARE: THORACIC & VASCULAR SURGICAL SPECIALTY SERVICES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MD418715	PA

General Provider Information

NPI Number	:	1609275478
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THORACIC & VASCULAR SURGICAL SPECIALTY SERVICES

Provider Business Mailing Address
First Line	:	20 EXPEDITION TRL
Second Line	:	SUITE 110B
City	:	GETTYSBURG
State	:	PA
Zip	:	17325-8598
Country	:	US
Telephone Number	:	443-676-6505
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 EXPEDITION TRL
Second Line	:	SUITE 110B
City	:	GETTYSBURG
State	:	PA
Zip	:	17325-8598
Country	:	US
Telephone Number	:	443-676-6505
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CIMENGA M TSHIBAKA
Credential	:	M.D.
Telephone Number	:	443-676-6505

Provider Enumeration Date	:	08/18/2014
Last Update Date	:	08/18/2014

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