Basic Information
| Provider Information | |||||||||
| NPI: | 1528354271 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIGHTHOUSE MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 E. PLEASANT VALLY BLVD | ||||||||
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| City: | ALTOONA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8149431271 | ||||||||
| FaxNumber: | 8149408516 | ||||||||
| Practice Location | |||||||||
| Address1: | 418 N LOGAN BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BURNHAM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170091816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172423900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2011 | ||||||||
| LastUpdateDate: | 02/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 81479431271 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MD438515 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2084N0400X | MD441685 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 208VP0014X | OS015480 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207LP2900X | MD044867E | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1020712560001 | 05 | PA | MEDICAID |