Healthcare Provider Details

I. General information

NPI: 1144589953
Provider Name (Legal Business Name): H.B.P.A. MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 FIRE HOUSE RD
GRANTVILLE PA
17028
US

IV. Provider business mailing address

1111 FIREHOUSE RD.
GRANTVILLE PA
17028
US

V. Phone/Fax

Practice location:
  • Phone: 717-469-2970
  • Fax: 717-469-7714
Mailing address:
  • Phone: 717-469-2970
  • Fax: 717-469-7714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN163-298L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS-006156-L
License Number StatePA

VIII. Authorized Official

Name: MR. TODD MOSTOLLER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 717-469-2970