Provider Demographics
NPI:1447231923
Name:LANCASTER GENERAL MEDICAL GROUP
Entity Type:Organization
Organization Name:LANCASTER GENERAL MEDICAL GROUP
Other - Org Name:LANDISVILLE FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:I
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-544-4001
Mailing Address - Street 1:405 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANDISVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17538-1812
Mailing Address - Country:US
Mailing Address - Phone:717-898-2413
Mailing Address - Fax:717-898-9142
Practice Address - Street 1:405 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANDISVILLE
Practice Address - State:PA
Practice Address - Zip Code:17538-1812
Practice Address - Country:US
Practice Address - Phone:717-898-2413
Practice Address - Fax:717-898-9142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA676677OtherAETNA CAP OFFICE#
PA3974095OtherAETNA HMO
PA1648901OtherHIGHMARK BLUE SHIELD
PA50041081OtherCAPITAL BLUE CROSS
PA1540390OtherGATEWAY HEALTH PLAN
PA7315670OtherAETNA NON-HMO
PA1007327490136Medicaid
PACN7614OtherRAILROAD MEDICARE
PAS1QEOtherGEISINGER HEALTH PLAN
PA1007327490136Medicaid