Provider Demographics
NPI:1346396363
Name:LOCK HAVEN EAR NOSE & THROAT PC
Entity Type:Organization
Organization Name:LOCK HAVEN EAR NOSE & THROAT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:FOULSHAM
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:570-748-6777
Mailing Address - Street 1:PO BOX 117
Mailing Address - Street 2:401 HIGH STREET
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-0117
Mailing Address - Country:US
Mailing Address - Phone:570-748-6777
Mailing Address - Fax:570-748-0110
Practice Address - Street 1:401 HIGH STREET
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-0117
Practice Address - Country:US
Practice Address - Phone:570-748-6777
Practice Address - Fax:570-748-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026474E207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001030532Medicaid
PA058467OtherBLUE CROSS BLUE SHIELD
PA1943384OtherPENNSYLVANIA BLUE SHIELD
PA186393205OtherGEISINGER HEALTH PLAN
PA1943384OtherPENNSYLVANIA BLUE SHIELD
PA119999Medicare PIN
PACL3005Medicare PIN
E55436Medicare UPIN