Provider Demographics
NPI:1124180427
Name:LANCASTER PA ENDOSCOPY ASC LLC
Entity Type:Organization
Organization Name:LANCASTER PA ENDOSCOPY ASC LLC
Other - Org Name:LANCASTER GASTROENTEROLOGY PROCEDURE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:2112 HARRISBURG PIKE
Mailing Address - Street 2:SUITE 323
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17604
Mailing Address - Country:US
Mailing Address - Phone:717-544-3569
Mailing Address - Fax:717-544-3570
Practice Address - Street 1:2112 HARRISBURG PIKE
Practice Address - Street 2:SUITE 323
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17604
Practice Address - Country:US
Practice Address - Phone:717-544-3569
Practice Address - Fax:717-544-3570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA17211501261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019852560001Medicaid
PA39C0001145Medicare Oscar/Certification
PA113878Medicare PIN