=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396607255
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEHIGH VALLEY PHYSICIAN GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2025
-----------------------------------------------------
Last Update Date | 12/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1251 S CEDAR CREST BLVD STE 109
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18103-6205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-434-2162
-----------------------------------------------------
Fax | 610-434-9370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 MACK BLVD
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18103-5622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-884-4500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER ENROLLMENT LIAISON
-----------------------------------------------------
Name | REBECCA DEMJAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 484-884-0684
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------