Provider Demographics
NPI:1972876472
Name:LYCOMING PHYSICIAN SERVICES,INC.
Entity type:Organization
Organization Name:LYCOMING PHYSICIAN SERVICES,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LAGERMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MBA
Authorized Official - Phone:570-743-1703
Mailing Address - Street 1:3040 N SUSQUEHANNA TRL
Mailing Address - Street 2:P.O. BOX 129
Mailing Address - City:SHAMOKIN DAM
Mailing Address - State:PA
Mailing Address - Zip Code:17876-9113
Mailing Address - Country:US
Mailing Address - Phone:717-743-1703
Mailing Address - Fax:570-743-1728
Practice Address - Street 1:3040 N SUSQUEHANNA TRL
Practice Address - Street 2:
Practice Address - City:SHAMOKIN DAM
Practice Address - State:PA
Practice Address - Zip Code:17876-9113
Practice Address - Country:US
Practice Address - Phone:570-743-1703
Practice Address - Fax:570-743-1728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA240488YHMKOtherMEDICARE PTAN