MEDICARE: DOROTHY B. LOLLATHIN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	50.002298RX	OH
2	363A00000X	Physician Assistant	10003160A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00278526	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	000000175652	OTHER		ANTHEM BCBS
5	001769308	OTHER		MOUNTAIN STATE BCBS
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	293560617	OTHER	OH	TRI CARE

General Provider Information

NPI Number	:	1932139839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOROTHY B. LOLLATHIN PA-C

Provider Business Mailing Address
First Line	:	1100 REID PARKWAY
Second Line	:	MEDICAL STAFF SERVICE
City	:	RICHMOND
State	:	IN
Zip	:	47374-1157
Country	:	US
Telephone Number	:	765-935-8905
Fax Number	:	765-939-4200

Provider Business Practice Location Address
First Line	:	1400 HIGHLAND RD STE 1
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-8810
Country	:	US
Telephone Number	:	765-935-8905
Fax Number	:	765-939-4200

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	05/17/2021

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Directions to “ DOROTHY B. LOLLATHIN PA-C” Practice Location

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