=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225238298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINNACLE HEALTH COMMUNITY CAMPUS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2007
-----------------------------------------------------
Last Update Date | 07/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 LONDONDERRY RD
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17109-5317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-657-7458
-----------------------------------------------------
Fax | 717-657-7555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4300 LONDONDERRY RD
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17109-5317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-657-7458
-----------------------------------------------------
Fax | 717-657-7555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INTERN TACKING INTERNAL MEDICINE
-----------------------------------------------------
Name | MRS. JUANITA MARIE KREISER
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 717-507-9450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | OT012032
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | OT012032
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------