Healthcare Provider Details

I. General information

NPI: 1548354509
Provider Name (Legal Business Name): LANCASTER COUNTY INTERNAL MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 OREGON PIKE # A SUITE 104
LANCASTER PA
17601-4206
US

IV. Provider business mailing address

PO BOX 309
WILLOW STREET PA
17584-0309
US

V. Phone/Fax

Practice location:
  • Phone: 717-397-7066
  • Fax: 717-397-7005
Mailing address:
  • Phone: 717-397-7066
  • Fax: 717-397-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS-006313L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberOS-006313L
License Number StatePA

VIII. Authorized Official

Name: CINDY S MAST
Title or Position: VICE PRESIDENT
Credential:
Phone: 717-397-7066