Healthcare Provider Details

I. General information

NPI: 1528102712
Provider Name (Legal Business Name): NITTANY ANESTHESIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 REGENT CT
STATE COLLEGE PA
16801-7965
US

IV. Provider business mailing address

PO BOX 223
STATE COLLEGE PA
16804-0223
US

V. Phone/Fax

Practice location:
  • Phone: 814-231-2102
  • Fax:
Mailing address:
  • Phone: 814-861-2177
  • Fax: 814-238-2278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1338851
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerKEYSTONE HEALTH PLAN CENT
# 2
Identifier1338851
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD
# 3
Identifier991B
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGEISINGER HEALTH PLAN
# 4
IdentifierDB8968
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRAILROAD MEDICARE
# 5
Identifier0018963220001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 6
Identifier03091200
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCAPITAL BLUE CROSS

VIII. Authorized Official

Name: RANDY MICHAEL HULEK
Title or Position: OFFICE MANAGER
Credential:
Phone: 814-861-2177