Basic Information
| Provider Information | |||||||||
| NPI: | 1679564330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAVALLEE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2005 TECHNOLOGY PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170509413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177912620 | ||||||||
| FaxNumber: | 7177912621 | ||||||||
| Practice Location | |||||||||
| Address1: | 2005 TECHNOLOGY PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170509413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177912620 | ||||||||
| FaxNumber: | 7177912621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | MD060390L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | 01049328A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200198600 | 05 | IN | MEDICAID | 002980953 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 068809600 | 05 | MD | MEDICAID | 102855069 | 05 | PA | MEDICAID |