Basic Information
| Provider Information | |||||||||
| NPI: | 1134164676 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LANCASTER GENERAL MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PENN MEDICINE LGHP FAMILY MEDICINE LINCOLN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1635 WEST MAIN STREET | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | EPHRATA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175221119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177380660 | ||||||||
| FaxNumber: | 7177380658 | ||||||||
| Practice Location | |||||||||
| Address1: | 1635 WEST MAIN STREET | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | EPHRATA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175221119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177380660 | ||||||||
| FaxNumber: | 7177380658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7175445010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LANCASTER GENERAL MEDICAL GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1555387 | 01 | PA | GATEWAY HEALTH PLAN | OTHER | 336301 | 01 | PA | AETNA CAP OFFICE# | OTHER | S1QF | 01 | PA | GEISINGER HEALTH PLAN | OTHER | 1007327490105 | 05 | PA | MEDICAID | 1282458 | 01 | PA | AETNA HMO | OTHER | 1016598680105 | 05 | PA | MEDICAID | 1875158 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 50060200 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 7991794 | 01 | PA | AETNA NON-HMO | OTHER |