Provider Demographics
NPI:1578575007
Name:LEBANON PEDIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:LEBANON PEDIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-838-6462
Mailing Address - Street 1:503 OAK ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-6246
Mailing Address - Country:US
Mailing Address - Phone:717-272-7695
Mailing Address - Fax:
Practice Address - Street 1:503 OAK ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-6246
Practice Address - Country:US
Practice Address - Phone:717-272-7695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016889E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA407754OtherHIGHMARK BLUE SHIELD
PA01543601OtherCAPITAL BLUE CROSS
PA1008514360001Medicaid
PA407754OtherHIGHMARK BLUE SHIELD