Basic Information
Provider Information | |||||||||
NPI: | 1265535645 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LANCASTER GENERAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PATHOLOGY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 555 N DUKE ST | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | PA | ||||||||
PostalCode: | 176022250 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175445511 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 555 N DUKE ST | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | PA | ||||||||
PostalCode: | 176022250 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7175445511 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2006 | ||||||||
LastUpdateDate: | 11/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KENNEDY | ||||||||
AuthorizedOfficialFirstName: | DENISE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
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 | 207ZP0105X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0102X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 000000128254 | 01 | PA | UNISON | OTHER | 2059152000 | 01 | PA | AMERIHEALTH 65 | OTHER | 30019299 | 01 | PA | KEYSTONE MERCY | OTHER | 1142441 | 01 | PA | AETNA - HMO | OTHER | 6150 | 01 | PA | HEALTH AMERICA | OTHER | 001366972 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | CK7852 | 01 | PA | RR MEDICARE | OTHER | 1002509 | 01 | PA | AMERIHEALTH MERCY | OTHER | 100771175 0005 | 05 | PA |   | MEDICAID | 640T | 01 | PA | GEISINGER | OTHER | 50056024 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1537625 | 01 | PA | GATEWAY | OTHER | 7798736 | 01 | PA | AETNA - NON HMO | OTHER |