Healthcare Provider Details

I. General information

NPI: 1861862591
Provider Name (Legal Business Name): INTERNISTS OF CENTRAL PENNSYLVANIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 LOWTHER ST
LEMOYNE PA
17043-2045
US

IV. Provider business mailing address

154 ERFORD RD APT 405
CAMP HILL PA
17011-1827
US

V. Phone/Fax

Practice location:
  • Phone: 717-774-1366
  • Fax:
Mailing address:
  • Phone: 740-504-3140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA057852
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA057852
License Number StatePA

VIII. Authorized Official

Name: GEORGIA JOHNSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 717-774-1366