Healthcare Provider Details

I. General information

NPI: 1235642968
Provider Name (Legal Business Name): PENNSYLVANIA PSYCHIATRIC MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N 3RD ST
HARRISBURG PA
17110-1904
US

IV. Provider business mailing address

PO BOX 826929
PHILADELPHIA PA
19182-6929
US

V. Phone/Fax

Practice location:
  • Phone: 717-782-6420
  • Fax:
Mailing address:
  • Phone: 717-782-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM DALY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 717-782-4742