Basic Information
| Provider Information | |||||||||
| NPI: | 1255352092 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LANCASTER GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PENN MEDICINE LGHP WALTER L. AUMENT FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 317 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | QUARRYVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175661184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177867383 | ||||||||
| FaxNumber: | 7177868635 | ||||||||
| Practice Location | |||||||||
| Address1: | 317 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | QUARRYVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175661184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177867383 | ||||||||
| FaxNumber: | 7177868635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7175445010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LANCASTER GENERAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001365404 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1518480 | 01 | PA | GATEWAY | OTHER | 50055821 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 100771175 0080 | 05 | PA | MEDICAID | 4512890 | 01 | PA | CIGNA | OTHER | 000000155103 | 01 | PA | UNISON - PCP | OTHER |