Healthcare Provider Details

I. General information

NPI: 1801433149
Provider Name (Legal Business Name): PENN STATE HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N 12TH ST
LEMOYNE PA
17043-1440
US

IV. Provider business mailing address

PO BOX 825972 PO BOX 825972
PHILADELPHIA PA
19182-5972
US

V. Phone/Fax

Practice location:
  • Phone: 717-234-2561
  • Fax: 717-236-1121
Mailing address:
  • Phone: 717-531-4859
  • Fax: 717-312-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACY L MOYER-SWINKO
Title or Position: VP/CHIEF FINANCIAL OFFICER
Credential:
Phone: 717-531-8477