Basic Information
| Provider Information | |||||||||
| NPI: | 1952321473 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEWISBURG CANCER CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1575 N OLD TRL | ||||||||
| Address2: | |||||||||
| City: | SELINSGROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178708381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703748555 | ||||||||
| FaxNumber: | 5703749933 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178376343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703748555 | ||||||||
| FaxNumber: | 5703749933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 11/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | SRIVASTAVA | ||||||||
| AuthorizedOfficialFirstName: | NAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5703748555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00196120600001 | 05 | PA | MEDICAID |