Provider Demographics
NPI:1891118667
Name:LYCOMING PHYSICAL MEDICINE PC
Entity type:Organization
Organization Name:LYCOMING PHYSICAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HAMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-916-4897
Mailing Address - Street 1:1111 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-5411
Mailing Address - Country:US
Mailing Address - Phone:570-916-4897
Mailing Address - Fax:570-322-8100
Practice Address - Street 1:1111 E 3RD ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-5411
Practice Address - Country:US
Practice Address - Phone:570-916-4897
Practice Address - Fax:570-322-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045007L207R00000X
PAMD070043L332B00000X
PADC004453L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADC004453LOtherLICENSE