Basic Information
Provider Information | |||||||||
NPI: | 1033170881 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SACRED HEART HEALTHCARE SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SACRED HEART PEDIATRIC ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 421 W CHEW ST | ||||||||
Address2: | PHYSICIAN ACCOUNTS | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181023406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6107765100 | ||||||||
FaxNumber: | 6106633113 | ||||||||
Practice Location | |||||||||
Address1: | 450 W CHEW ST | ||||||||
Address2: | SIGAL CENTER 2ND FLOOR PEDS ASSOCIATES | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181023434 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6107765160 | ||||||||
FaxNumber: | 6106064476 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2006 | ||||||||
LastUpdateDate: | 02/25/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LANSHE | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | VP LEGAL AFFAIRS | ||||||||
AuthorizedOfficialTelephone: | 6107765100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 0869773001 | 01 |   | IBC | OTHER | 1019770 | 01 |   | AMERIHEALTH MERCY HEALTH | OTHER | 837784 | 01 | PA | HIGHMARK BLS GROUP # | OTHER | 4521958 | 01 |   | AETNA PPO | OTHER | 0098942 | 01 |   | AETNA HMO | OTHER | 1554755 | 01 |   | GATEWAY | OTHER | 03161500 | 01 | PA | CBC GROUP # | OTHER |