Healthcare Provider Details

I. General information

NPI: 1134874779
Provider Name (Legal Business Name): PENN STATE HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2022
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 POPLAR CHURCH RD STE 400
CAMP HILL PA
17011-2203
US

IV. Provider business mailing address

PO BOX 825972
PHILADELPHIA PA
19182-5972
US

V. Phone/Fax

Practice location:
  • Phone: 717-724-6450
  • Fax: 717-724-6451
Mailing address:
  • Phone: 717-531-4859
  • Fax: 717-312-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACY L MOYER-SWINKO
Title or Position: VP/CHIEF FINANCIAL OFFICER
Credential:
Phone: 717-531-8477