Provider Demographics
NPI:1093944779
Name:HANOVER HEALTH CORPORATION
Entity Type:Organization
Organization Name:HANOVER HEALTH CORPORATION
Other - Org Name:HANOVER MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM CEO/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:GASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-316-2153
Mailing Address - Street 1:300 HIGHLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-2297
Mailing Address - Country:US
Mailing Address - Phone:717-316-3711
Mailing Address - Fax:717-646-0188
Practice Address - Street 1:300 HIGHLAND AVENUE
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-2297
Practice Address - Country:US
Practice Address - Phone:717-637-3711
Practice Address - Fax:717-646-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 207Y00000X, 208100000X, 208600000X, 261QM1300X
PA261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPENDINGMedicaid
PA102387691Medicaid
PA102387691Medicaid
PAPENDINGMedicare PIN