Basic Information
| Provider Information | |||||||||
| NPI: | 1598048787 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIGHTHOUSE MEDICAL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTRAL PA PAIN MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 N FRONT ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PHILIPSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168662303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143422333 | ||||||||
| FaxNumber: | 8143422277 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 N FRONT ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PHILIPSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168662303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143422333 | ||||||||
| FaxNumber: | 8143422277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2011 | ||||||||
| LastUpdateDate: | 09/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | STEELE | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8147934833 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MC438515 | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208VP0014X | MD044867E | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1020712560001 | 05 | PA | MEDICAID |