Provider Demographics
NPI:1215143656
Name:LYN-SUE, JEROME RUDOLPH (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:RUDOLPH
Last Name:LYN-SUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:717-531-8887
Practice Address - Fax:717-531-4729
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD65607208600000X
PAMD440535208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC311460Medicaid
SCGP4953OtherMEDICAID GROUP #
SC5551OtherMEDICARE GROUP #
PA1024785260001Medicaid
SCP00775529OtherRAILROAD MEDICARE ID-AFTER 5/1/2009
SCAA32825551Medicare PIN