Healthcare Provider Details

I. General information

NPI: 1164405593
Provider Name (Legal Business Name): LANCASTER GENERAL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 WEST 2ND AVENUE
LITITZ PA
17543-1816
US

IV. Provider business mailing address

562 WEST 2ND AVENUE
LITITZ PA
17543-1816
US

V. Phone/Fax

Practice location:
  • Phone: 717-626-2167
  • Fax: 717-626-1915
Mailing address:
  • Phone: 717-626-2167
  • Fax: 717-626-1915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1007327490074
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier128360
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BLUE SHIELD
# 3
Identifier5913568
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA NON-HMO
# 4
IdentifierCC3129
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRAILROAD MEDICARE
# 5
Identifier1294
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA HMO
# 6
Identifier85047
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA CAP OFFICE#
# 7
Identifier03093600
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCAPITAL BLUE CROSS
# 8
IdentifierS1QG
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGEISINGER HEALTH PLAN
# 9
Identifier1518494
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGATEWAY HEALTH PLAN

VIII. Authorized Official

Name: DENISE KENNEDY
Title or Position: VICE PRESIDENT FINANCIAL SERVICES
Credential:
Phone: 717-544-5010