Healthcare Provider Details

I. General information

NPI: 1851956171
Provider Name (Legal Business Name): LEHIGH VALLEY PHYSICIAN GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 W FAIRMONT ST
ALLENTOWN PA
18104-3118
US

IV. Provider business mailing address

1605 N CEDAR CREST BLVD STE 110B
ALLENTOWN PA
18104-2351
US

V. Phone/Fax

Practice location:
  • Phone: 610-841-2798
  • Fax: 610-841-2796
Mailing address:
  • Phone: 610-973-1410
  • Fax: 610-973-1449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BREANNA SANTIAGO
Title or Position: PROVIDER ENROLLMENT LIAISON
Credential:
Phone: 484-884-0661