Healthcare Provider Details

I. General information

NPI: 1609347152
Provider Name (Legal Business Name): PENN STATE HEALTH COMMUNITY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 02/12/2022
Certification Date: 02/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 WALNUT ST
WEST READING PA
19611-1242
US

IV. Provider business mailing address

655 WALNUT ST
WEST READING PA
19611-1242
US

V. Phone/Fax

Practice location:
  • Phone: 610-372-9222
  • Fax: 610-372-0232
Mailing address:
  • Phone: 610-372-9222
  • Fax: 610-372-0232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: PAULA TINCH
Title or Position: VICE PRESIDENT CHIEF FINANCIAL OFFI
Credential:
Phone: 717-531-1313