Basic Information
| Provider Information | |||||||||
| NPI: | 1265578314 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LANCASTER GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PENN MEDICINE LGHP COMPREHENSIVE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 554 N DUKE ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176022225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175444943 | ||||||||
| FaxNumber: | 7175441961 | ||||||||
| Practice Location | |||||||||
| Address1: | 554 N DUKE ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176022225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175444943 | ||||||||
| FaxNumber: | 7175441961 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7175445010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LANCASTER GENERAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207V00000X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207Q00000X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 50055923 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1812923 | 01 | PA | HIGHMARK GROUP# | OTHER | 20045466 | 01 | PA | AMERIHEALTH MERCY | OTHER | S1P1 | 01 | PA | GEISINGER | OTHER | 000000134934 | 01 | PA | UNISON - HBP GRP# | OTHER | 000000127890 | 01 | PA | UNISON - FPR GRP# | OTHER | 2648762000 | 01 | PA | AMERIHEALTH 65 | OTHER | 100771175 0005 | 05 | PA | MEDICAID |