1598048787 NPI number — LIGHTHOUSE MEDICAL, LLC

Table of content: (NPI 1598048787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598048787 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:
CENTRAL PA 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:
1598048787
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 N FRONT ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
PHILIPSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16866-2303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-342-2333
Provider Business Mailing Address Fax Number:
814-342-2277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 N FRONT ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PHILIPSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16866-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-342-2333
Provider Business Practice Location Address Fax Number:
814-342-2277
Provider Enumeration Date:
09/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
STEELE
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
B
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
814-793-4833

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  MC438515 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , 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: 1020712560001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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