Healthcare Provider Details

I. General information

NPI: 1780752378
Provider Name (Legal Business Name): MOUNT NITTANY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E PARK AVE
STATE COLLEGE PA
16803-6701
US

IV. Provider business mailing address

1800 E PARK AVE
STATE COLLEGE PA
16803-6701
US

V. Phone/Fax

Practice location:
  • Phone: 814-231-7000
  • Fax:
Mailing address:
  • Phone: 814-231-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number550301
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1007466550017
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: BRYAN ROACH
Title or Position: CFO
Credential:
Phone: 814-234-6148