Basic Information
| Provider Information | |||||||||
| NPI: | 1144363755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAFTON | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAGENMAN | ||||||||
| OtherFirstName: | LORI | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 858 | ||||||||
| Address2: | MC A410 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170330858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002431455 | ||||||||
| FaxNumber: | 7175317269 | ||||||||
| Practice Location | |||||||||
| Address1: | 1135 OLDE W CHOCOLATE AVE | ||||||||
| Address2: | PENN STATE HERSHEY REHABILITATION HOSPITAL | ||||||||
| City: | HUMMELSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170369188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175317010 | ||||||||
| FaxNumber: | 7175317102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | P17893 | MD | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 2007-00403 | NC | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P0301X | MD427408 | PA | Y |
ID Information
| ID | Type | State | Issuer | Description | 145VP | 01 | NC | NCBCBS | OTHER | 5906924 | 05 | NC | MEDICAID | 1144363755 | 05 | NC | MEDICAID | N03007 | 05 | SC | MEDICAID |