Provider Demographics
NPI:1730132580
Name:GEORGANDELLIS, LUCAS (MD)
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:
Last Name:GEORGANDELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VINE ST
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1027
Mailing Address - Country:US
Mailing Address - Phone:740-645-4237
Mailing Address - Fax:
Practice Address - Street 1:1 VINE ST
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1027
Practice Address - Country:US
Practice Address - Phone:740-645-4237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-2167207R00000X, 207RC0200X, 207RN0300X
WV21526207R00000X, 207RC0200X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1730132580OtherNPI
001714146OtherMOUNTAIN STATE BCBS
WV2004717000Medicaid
OH2400708OtherMOLINA MEDICAID
OH310917085118OtherCARESOURCE MEDICAID
P00006241OtherRR MEDICARE
OH000000185210OtherUNISON MEDICAID
000000272527OtherANTHEM BCBS
OH268597383-00OtherOH BUREAU WORKERS COMP
OH000000185210OtherUNISON MEDICAID
OH268597383-00OtherOH BUREAU WORKERS COMP
OH4103613Medicare PIN