Basic Information
Provider Information | |||||||||
NPI: | 1942609599 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LEHIGH VALLEY PHYSICIAN GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 783311 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191783311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4848844500 | ||||||||
FaxNumber: | 4848840699 | ||||||||
Practice Location | |||||||||
Address1: | 564 W BROAD ST | ||||||||
Address2: | SUITE 2 | ||||||||
City: | HAZLETON | ||||||||
State: | PA | ||||||||
PostalCode: | 182016108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5705016220 | ||||||||
FaxNumber: | 5705012795 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2014 | ||||||||
LastUpdateDate: | 07/18/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROSSI | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
AuthorizedOfficialTelephone: | 4848844500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.