Provider Demographics
NPI:1184020174
Name:DR. JEANVICKEY LUSK, M.D. & CO. P.C.
Entity Type:Organization
Organization Name:DR. JEANVICKEY LUSK, M.D. & CO. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANVICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSK, M.D.
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-200-8447
Mailing Address - Street 1:P.O. BOX 60940
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 GYPSY LANE
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406
Practice Address - Country:US
Practice Address - Phone:215-200-8447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty