Healthcare Provider Details

I. General information

NPI: 1457110793
Provider Name (Legal Business Name): PENN STATE HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CRYSTAL A DR
HERSHEY PA
17033-9524
US

IV. Provider business mailing address

PO BOX 825972
PHILADELPHIA PA
19182-5972
US

V. Phone/Fax

Practice location:
  • Phone: 833-774-3627
  • Fax:
Mailing address:
  • Phone: 717-531-4859
  • Fax: 717-312-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACY L MOYER-SWINKO
Title or Position: EXECUTIVE VICE PRESIDENT/CFO
Credential:
Phone: 717-531-8477