Healthcare Provider Details

I. General information

NPI: 1598164337
Provider Name (Legal Business Name): TRICORNE PRIMARY NERVE & JOINT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 S GEORGE ST SUITE W-2
YORK PA
17403-4594
US

IV. Provider business mailing address

2200 S GEORGE ST SUITE W-2
YORK PA
17403-4594
US

V. Phone/Fax

Practice location:
  • Phone: 717-747-3220
  • Fax: 717-747-3338
Mailing address:
  • Phone: 717-747-3220
  • Fax: 717-747-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberMD427825
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberMD427825
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberMD427825
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberMD427825
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberMD427825
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberBE8901060
License Number StatePA
# 7
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD427825
License Number StatePA

VIII. Authorized Official

Name: DR. EARL W EDWARDS
Title or Position: SOLE MEMBER
Credential: M.D.
Phone: 717-747-3220