1528093937 NPI number — KENT T LANCASTER MD

Table of content: KENT T LANCASTER MD (NPI 1528093937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528093937 NPI number — KENT T LANCASTER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANCASTER
Provider First Name:
KENT
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1528093937
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4699
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47903-4699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-449-2732
Provider Business Mailing Address Fax Number:
765-449-1196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1411 S. CREASY LANE
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47905-7433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-447-7447
Provider Business Practice Location Address Fax Number:
765-807-0553
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  4301406274 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30001101191 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 200933980 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2927880 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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