Basic Information
Provider Information | |||||||||
NPI: | 1336169390 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOYLE | ||||||||
FirstName: | JENNY | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 HOSPITAL DR | ||||||||
Address2: | SUITE 306 | ||||||||
City: | LEWISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 178379314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5705224110 | ||||||||
FaxNumber: | 5707683911 | ||||||||
Practice Location | |||||||||
Address1: | 1 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | LEWISBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 178379350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5705222510 | ||||||||
FaxNumber: | 5707683911 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2006 | ||||||||
LastUpdateDate: | 03/17/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | MD029423E | PA | N |   | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | MD029423E | PA | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 10933540004 | 05 | PA |   | MEDICAID | 50010277 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 321847 | 01 | PA | HEALTH AMERICA | OTHER | 410394 | 01 | PA | BLUE SHIELD | OTHER | P00004773 | 01 | PA | RAILROAD MEDICARE | OTHER |