Healthcare Provider Details

I. General information

NPI: 1497409155
Provider Name (Legal Business Name): PENN STATE HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 N 21ST ST
CAMP HILL PA
17011-2204
US

IV. Provider business mailing address

PO BOX 825972
PHILADELPHIA PA
19182-5972
US

V. Phone/Fax

Practice location:
  • Phone: 717-972-4448
  • Fax: 717-972-7366
Mailing address:
  • Phone: 717-531-4859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
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