Healthcare Provider Details

I. General information

NPI: 1225783871
Provider Name (Legal Business Name): PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
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 848
HERSHEY PA
17033-0848
US

V. Phone/Fax

Practice location:
  • Phone: 717-972-7919
  • Fax: 717-763-2272
Mailing address:
  • Phone: 610-208-8818
  • Fax: 717-312-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARGARET YUSKOVIC
Title or Position: DELEGATED
Credential:
Phone: 610-208-8818