Healthcare Provider Details

I. General information

NPI: 1891035937
Provider Name (Legal Business Name): CONCUSSION MANAGEMENT CENTER OF CENTRAL PA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NASON DR SUITE 104
ROARING SPRING PA
16673-1212
US

IV. Provider business mailing address

111 NASON DR SUITE 104
ROARING SPRING PA
16673-1212
US

V. Phone/Fax

Practice location:
  • Phone: 814-224-6096
  • Fax: 814-224-6095
Mailing address:
  • Phone: 814-224-6096
  • Fax: 814-224-6095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN A BAKER
Title or Position: PHYSICIAN
Credential: DO
Phone: 814-224-6096