Provider Demographics
NPI:1477743409
Name:BRUCE M LIDSTON AND ALLEN B ETTENGER PARTNERS
Entity Type:Organization
Organization Name:BRUCE M LIDSTON AND ALLEN B ETTENGER PARTNERS
Other - Org Name:HUNTINGDON PEDIATRIC ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIDSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-643-0531
Mailing Address - Street 1:1227 WARM SPRINGS AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:16652-2300
Mailing Address - Country:US
Mailing Address - Phone:814-643-0531
Mailing Address - Fax:814-643-6637
Practice Address - Street 1:1227 WARM SPRINGS AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2300
Practice Address - Country:US
Practice Address - Phone:814-643-0531
Practice Address - Fax:814-643-6637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA010231291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007685540005Medicaid