Basic Information
| Provider Information | |||||||||
| NPI: | 1275582843 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONESTOGA EMERGENCY PHYSICIANS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 LAKESIDE DR | ||||||||
| Address2: | |||||||||
| City: | HORSHAM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190442319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002478060 | ||||||||
| FaxNumber: | 2159572875 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176033363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172918211 | ||||||||
| FaxNumber: | 7172918090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 12/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4694012386 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | CO1483119 | 01 | PA | BLUE SHIELD | OTHER | 50020594 | 01 | PA | BLUE CROSS | OTHER | 0019617990001 | 05 | PA | MEDICAID |