1235197104 NPI number — HANOVER FAMILY PRACTICE ASSOCIATES, LLC

Table of content: (NPI 1235197104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235197104 NPI number — HANOVER FAMILY PRACTICE ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HANOVER FAMILY PRACTICE ASSOCIATES, LLC
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:
Provider Other Organization Name Type Code:
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:
1235197104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 PENN ST
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:
17331-1929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-632-4449
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 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:
17331-1929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-632-4449
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOUL
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
717-632-0774

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 182943 . This is a "HEALTH AMERICA/ ASSURANCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5337129 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 827916 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0859603000 . This is a "INDEPENDANCE BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 02307000 . This is a "BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 238893 . This is a "MAMSI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007518240013 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CC6198 . This is a "PALMETTO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1520197 . This is a "GATEWAY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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