Basic Information
| Provider Information | |||||||||
| NPI: | 1093944779 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HANOVER HEALTH CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HANOVER MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HIGHLAND AVENUE | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173312297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173163711 | ||||||||
| FaxNumber: | 7176460188 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HIGHLAND AVENUE | ||||||||
| Address2: | |||||||||
| City: | HANOVER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 173312297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176373711 | ||||||||
| FaxNumber: | 7176460188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 01/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | GASKINS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CEO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 7173162153 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 261QM1300X | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | PA | MEDICAID | 102387691 | 05 | PA | MEDICAID |