Healthcare Provider Details

I. General information

NPI: 1124064019
Provider Name (Legal Business Name): FIFTH AVENUE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 5TH AVE
CHAMBERSBURG PA
17201-4224
US

IV. Provider business mailing address

835 5TH AVE
CHAMBERSBURG PA
17201-4224
US

V. Phone/Fax

Practice location:
  • Phone: 717-217-4312
  • Fax: 717-217-4314
Mailing address:
  • Phone: 717-217-4312
  • Fax: 717-217-4314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MELANIE MOATS
Title or Position: CENTER DIRECTOR
Credential:
Phone: 717-217-4312