Provider Demographics
NPI:1083887822
Name:GEORGE A LIGHTBOURN MD PC
Entity Type:Organization
Organization Name:GEORGE A LIGHTBOURN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEROGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIGHTBOURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-353-6599
Mailing Address - Street 1:PO BOX 937
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-0937
Mailing Address - Country:US
Mailing Address - Phone:248-353-6599
Mailing Address - Fax:248-353-6566
Practice Address - Street 1:29600 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1016
Practice Address - Country:US
Practice Address - Phone:248-353-6599
Practice Address - Fax:248-353-6566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101346646Medicaid
3408257131OtherBLUE CROSS BLUE SHIELD
1123970001OtherWELLNESS PLAN
3408257131OtherBLUE CARE NETWORK
MI0825713Medicare PIN
1123970001OtherWELLNESS PLAN