Basic Information
| Provider Information | |||||||||
| NPI: | 1326008228 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SACRED HEART HEALTHCARE SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HANOVER FAMILY MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 W CHEW ST | ||||||||
| Address2: | PHYSICIAN ACCOUNTS | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181023406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107765100 | ||||||||
| FaxNumber: | 6106633113 | ||||||||
| Practice Location | |||||||||
| Address1: | 1210 HANOVER AVE | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181092017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104376490 | ||||||||
| FaxNumber: | 6104374151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 02/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | LANSHE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VP LEGAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 6107765141 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1519695 | 01 | GATEWAY ASSURED | OTHER | 564229 | 01 | PA | HIGHMARK BLS GROUP # | OTHER | 0006472 | 01 | AETNA HMO | OTHER | 0218423001 | 01 | IBC | OTHER | 02400200 | 01 | PA | CBC GROUP # | OTHER | 5844495 | 01 | AETNA PPO | OTHER | 47661 | 01 | AMERIHEALTH MERCY HEALTH | OTHER |