Provider Demographics
NPI:1346246436
Name:LEBANON DIAGNOSTIC IMAGING, LLC
Entity Type:Organization
Organization Name:LEBANON DIAGNOSTIC IMAGING, LLC
Other - Org Name:LEBANON DIAGNOSTIC IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AM
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-206-6198
Mailing Address - Street 1:960 ISABEL DRIVE
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:717-306-4400
Mailing Address - Fax:717-306-4442
Practice Address - Street 1:462 GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-7351
Practice Address - Country:US
Practice Address - Phone:717-263-4999
Practice Address - Fax:717-263-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101204607Medicaid
PA101204607Medicaid