Healthcare Provider Details

I. General information

NPI: 1528321015
Provider Name (Legal Business Name): MOUNT NITTANY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 WELLNESS WAY
STATE COLLEGE PA
16803-6797
US

IV. Provider business mailing address

PO BOX 411847
BOSTON MA
02241-1834
US

V. Phone/Fax

Practice location:
  • Phone: 814-231-7168
  • Fax: 814-235-7381
Mailing address:
  • Phone: 814-234-6199
  • Fax: 814-235-7843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: BRYAN ROACH
Title or Position: CFO
Credential:
Phone: 814-234-6184