1841580495 NPI number — LIGHTHOUSE MEDICAL LLC

Table of content: (NPI 1841580495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841580495 NPI number — LIGHTHOUSE MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE MEDICAL 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:
LIGHTHOUSE MEDICAL PAIN MANAGEMENT
Provider Other Organization Name Type Code:
3
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:
1841580495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 E. PLEASANT VALLEY BLVD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTOONA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-943-1271
Provider Business Mailing Address Fax Number:
814-940-8516

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 GLENN ST
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
CUMBERLAND
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21502-2460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-722-7246
Provider Business Practice Location Address Fax Number:
301-777-2624
Provider Enumeration Date:
04/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
814-943-1271

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  MD044867E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3366359 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: Y925 . This is a "CAREFIST BC/BS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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