Provider Demographics
NPI:1588031157
Name:LINCOLN MEDICAL PRACTICE INC
Entity Type:Organization
Organization Name:LINCOLN MEDICAL PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSCIAN
Authorized Official - Prefix:
Authorized Official - First Name:SARALA
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANAPURAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-542-1140
Mailing Address - Street 1:89 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-6315
Mailing Address - Country:US
Mailing Address - Phone:916-434-8800
Mailing Address - Fax:
Practice Address - Street 1:89 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-6315
Practice Address - Country:US
Practice Address - Phone:916-434-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-29
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA137432261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA159302Medicare PIN