Provider Demographics
NPI:1124406426
Name:LYCOMING PHYSICAL MEDICINE
Entity Type:Organization
Organization Name:LYCOMING PHYSICAL MEDICINE
Other - Org Name:LYCOMING PHYSICAL MEDICINE LEMOYNE DME
Other - Org Type:Doing Business As
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:570-326-0400
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:570-326-0400
Mailing Address - Fax:
Practice Address - Street 1:2 LEMOYNE DR
Practice Address - Street 2:STE 203
Practice Address - City:LEMOYNE
Practice Address - State:PA
Practice Address - Zip Code:17043-1222
Practice Address - Country:US
Practice Address - Phone:717-763-1222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045007L332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies