1396887634 NPI number — HANOVER HEALTH CORPORATION, INC.

Table of content: (NPI 1396887634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396887634 NPI number — HANOVER HEALTH CORPORATION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HANOVER HEALTH CORPORATION, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CARLOS MEDINA, M.D.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396887634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 HIGHLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANOVER
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17331-2297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-633-3511
Provider Business Mailing Address Fax Number:
717-646-0188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 PENN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HANOVER
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17331-1956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-632-3220
Provider Business Practice Location Address Fax Number:
717-632-3220
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OLEJNIK
Authorized Official First Name:
MARILYN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
717-637-3711

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PENDING , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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