Basic Information
Provider Information | |||||||||
NPI: | 1366403370 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SACRED HEART HEALTHCARE SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ZIONSVILLE FAMILY PRACTICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 5802 CHESTNUT ST | ||||||||
Address2: |   | ||||||||
City: | ZIONSVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 180922105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109659100 | ||||||||
FaxNumber: | 6109679609 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2006 | ||||||||
LastUpdateDate: | 02/25/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LANSHE | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | VP LEGAL AFFAIRS | ||||||||
AuthorizedOfficialTelephone: | 6107765141 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 174971 | 01 | PA | HIGHMARK BS GROUP NUMBER | OTHER | 5936066 | 01 |   | AETNA PPO | OTHER | 03161000 | 01 | PA | CBC GROUP NUMBER | OTHER | 0550891 | 01 |   | AETNA HMO | OTHER | 0178860001 | 01 |   | IBC | OTHER | 1521933 | 01 |   | GATEWAY | OTHER |