Provider Demographics
NPI:1932881489
Name:LEBANON WELLNESS
Entity type:Organization
Organization Name:LEBANON WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAVKAT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUZIEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-297-7900
Mailing Address - Street 1:974 ISABEL DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7482
Mailing Address - Country:US
Mailing Address - Phone:717-297-7900
Mailing Address - Fax:717-276-7323
Practice Address - Street 1:974 ISABEL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7482
Practice Address - Country:US
Practice Address - Phone:717-297-7900
Practice Address - Fax:717-276-7323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-03
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104547266-0001Medicaid