Healthcare Provider Details

I. General information

NPI: 1023694262
Provider Name (Legal Business Name): SPECIALTY MEDICAL CARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2214 N ATHERTON ST
STATE COLLEGE PA
16803-1544
US

IV. Provider business mailing address

320 EXTON CMNS
EXTON PA
19341-2450
US

V. Phone/Fax

Practice location:
  • Phone: 866-268-6609
  • Fax: 866-610-4542
Mailing address:
  • Phone: 866-268-6609
  • Fax: 866-610-4542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MELISSA A CALLAHAN
Title or Position: PRESIDENT
Credential: AGPCNP-BC
Phone: 866-268-6609