Basic Information
| Provider Information | |||||||||
| NPI: | 1285654467 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LANCASTER GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PENN MEDICINE LGHP GERIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2112 HARRISBURG PIKE | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176012644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175443022 | ||||||||
| FaxNumber: | 7175443021 | ||||||||
| Practice Location | |||||||||
| Address1: | 2112 HARRISBURG PIKE | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176012644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175443022 | ||||||||
| FaxNumber: | 7175443021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7175445010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LANCASTER GENERAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | CK7852 | 01 | PA | RR MEDICARE | OTHER | 100771175 0079 | 05 | PA | MEDICAID | 2087959001 | 01 | PA | AMERIHEALTH 65 | OTHER | 7577709 | 01 | PA | AETNA-NON HMO | OTHER | 1528755 | 01 | PA | GATEWAY | OTHER | 186777 | 01 | PA | HEALTH AMERICA | OTHER | 000000136758 | 01 | PA | UNISON | OTHER | 001399238 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 20028996 | 01 | PA | AMERIHEALTH MERCY | OTHER | 3966887 | 01 | PA | AETNA-HMO | OTHER | 50055898 | 01 | PA | CAPITAL BLUE CROSS | OTHER | S1P6 | 01 | PA | GEISINGER | OTHER |