MEDICARE: PEQUEA VALLEY COMMUNITY MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1336486356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEQUEA VALLEY COMMUNITY MEDICINE

Provider Business Mailing Address
First Line	:	836 HOUSTON RUN DR
Second Line	:	SUITE 201
City	:	GAP
State	:	PA
Zip	:	17527-9496
Country	:	US
Telephone Number	:	717-442-9505
Fax Number	:	717-442-9531

Provider Business Practice Location Address
First Line	:	836 HOUSTON RUN DR
Second Line	:	SUITE 201
City	:	GAP
State	:	PA
Zip	:	17527-9496
Country	:	US
Telephone Number	:	717-442-9505
Fax Number	:	717-442-9531

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JESSICA R LACORTE
Credential	:	RN
Telephone Number	:	717-442-9505

Provider Enumeration Date	:	01/10/2013
Last Update Date	:	01/10/2013

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Directions to “PEQUEA VALLEY COMMUNITY MEDICINE ” Practice Location

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