1417903048 NPI number — LIGHTHOUSE INTERNAL MEDICINE P.A.

Table of content: (NPI 1417903048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417903048 NPI number — LIGHTHOUSE INTERNAL MEDICINE P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE INTERNAL MEDICINE P.A.
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:
1417903048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
909 LAKEVIEW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILFORD
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19963-1731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-422-5506
Provider Business Mailing Address Fax Number:
302-422-5507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 LAKEVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILFORD
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19963-1731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-422-5506
Provider Business Practice Location Address Fax Number:
302-422-5507
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALTERS
Authorized Official First Name:
JOSIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
302-422-5506

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  C100006175 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1000036273 . This is a "DELAWARE PHYSICIANS CARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: DD5833 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 1000036273 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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