Healthcare Provider Details

I. General information

NPI: 1124559679
Provider Name (Legal Business Name): MIDATLANTIC ENDOSCOPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 09/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 HARRISBURG PIKE SUITE 323
LANCASTER PA
17601-2644
US

IV. Provider business mailing address

2112 HARRISBURG PIKE SUITE 323
LANCASTER PA
17601-2644
US

V. Phone/Fax

Practice location:
  • Phone: 717-544-3569
  • Fax:
Mailing address:
  • Phone: 717-544-3569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number17211501
License Number StatePA

VIII. Authorized Official

Name: MR. PHILLIP A. CLENDENIN
Title or Position: PRESIDENT
Credential:
Phone: 615-665-1283