Basic Information
| Provider Information | |||||||||
| NPI: | 1689636094 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SACRED HEART HEALTHCARE SYSTEM | ||||||||
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| OtherOrganizationName: | SACRED HEART MEDICAL ASSOCIATES - NEUROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 450 W CHEW ST | ||||||||
| Address2: | SIGAL CENTER SUITE 204 SHMA NEUROLOGY | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181023434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107765491 | ||||||||
| FaxNumber: | 6106064432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 02/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | LANSHE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VP LEGAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 6107765141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0679828000 | 01 | IBC | OTHER | 50047325 | 01 | PA | CBC GROUP NUMBER | OTHER | 0459718 | 01 | AETNA HMO | OTHER | 1531299 | 01 | GATEWAY HEALTH PLAN | OTHER | 1948543 | 01 | HIGHMARK BLUE SHIELD | OTHER | 5212022 | 01 | AETNA PPO | OTHER | 20021227 | 01 | AMERIHEALTH MERCY HEALTH | OTHER |