Healthcare Provider Details

I. General information

NPI: 1073816690
Provider Name (Legal Business Name): PENN STATE HERSHEY ENDOSCOPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2010
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 COLONNADE WAY
STATE COLLEGE PA
16803-2309
US

IV. Provider business mailing address

32 COLONNADE WAY
STATE COLLEGE PA
16803-2309
US

V. Phone/Fax

Practice location:
  • Phone: 814-272-4481
  • Fax: 814-272-4470
Mailing address:
  • Phone: 814-272-4481
  • Fax: 814-272-4470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number2287I501
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier39C0001291
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerMEDICARE CCN

VIII. Authorized Official

Name: DR. JOEL HAIGHT
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 814-272-4481