Basic Information
| Provider Information | |||||||||
| NPI: | 1669566337 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LANCASTER GENERAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PENN MEDICINE LGHP FAMILY & MATERNITY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 694 GOOD DR | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176012433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175443737 | ||||||||
| FaxNumber: | 7175443739 | ||||||||
| Practice Location | |||||||||
| Address1: | 694 GOOD DR | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176012433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175443737 | ||||||||
| FaxNumber: | 7175443739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7175445010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LANCASTER GENERAL HOSPITAL | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000126161 | 01 | PA | UNISON-HBP GROUP# | OTHER | 244630 | 01 | PA | HEALTH AMERICA | OTHER | 7382867 | 01 | PA | AETNA/OB-GYN NON-HMO GROUP# | OTHER | 001366749 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 660T | 01 | PA | GEISINGER | OTHER | CK7852 | 01 | PA | RR MEDICARE | OTHER | 50056041 | 01 | PA | CAPITAL BLUE CROSS | OTHER | S1P7 | 01 | PA | GEISINGER | OTHER | 7382867 | 01 | PA | AETNA/NON-HMO-PCP# | OTHER | 1511660 | 01 | PA | GATEWAY | OTHER | 2059089000 | 01 | PA | AMERIHEALTH 65 | OTHER | 000000138301 | 01 | PA | UNISON-PCP GROUP# | OTHER | 1419055 | 01 | PA | AETNA-HMO/OB-GYN GROUP# | OTHER | 1418983 | 01 | PA | AETNA-HMO/PCP GRP# | OTHER | 20010267 | 01 | PA | AMERIHEALTH MERCY | OTHER | 30001348 | 01 | PA | KEYSTONE MERCY | OTHER | 100771175 0077 | 05 | PA | MEDICAID |