Basic Information
| Provider Information | |||||||||
| NPI: | 1366438590 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LANCASTER GENERAL MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PENN MEDICINE LGHP DIABETES & ENDOCRINOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2112 HARRISBURG PIKE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176012644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175443059 | ||||||||
| FaxNumber: | 7175443638 | ||||||||
| Practice Location | |||||||||
| Address1: | 2112 HARRISBURG PIKE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176012644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175443059 | ||||||||
| FaxNumber: | 7175443638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7175445010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 1449920 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 5991102 | 01 | PA | AETNA NON-HMO | OTHER | 1007327490102 | 05 | PA | MEDICAID | 4699 | 01 | PA | GEISINGER HEALTH PLAN | OTHER | 1003073 | 01 | PA | AMERIHEALTH MERCY HEALTH | OTHER | CD6279 | 01 | PA | RAILROAD MEDICARE | OTHER | 116085 | 01 | PA | AETNA HMO | OTHER | 50008354 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1529799 | 01 | PA | GATEWAY HEALTH PLAN | OTHER |