Provider Demographics
NPI:1831253467
Name:PEQUEA VALLEY INTERNAL MEDICINE, INC.
Entity type:Organization
Organization Name:PEQUEA VALLEY INTERNAL MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:R
Authorized Official - Last Name:LACORTE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:717-560-3505
Mailing Address - Street 1:1725 OREGON PIKE
Mailing Address - Street 2:SUITE 107 B
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-4206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1725 OREGON PIKE
Practice Address - Street 2:SUITE 107 B
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4206
Practice Address - Country:US
Practice Address - Phone:717-560-3505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADC7495OtherRR MCR
PA1646737OtherBLUESHIELD
PA50041137OtherCAP BC
PA0016560860002Medicaid
PA0016560860002Medicaid
PA1646737OtherBLUESHIELD