Provider Demographics
NPI:1740611425
Name:LISBON MEDICAL GROUP
Entity Type:Organization
Organization Name:LISBON MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-C
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNIE
Authorized Official - Middle Name:STERLING
Authorized Official - Last Name:COUGLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:315-393-3227
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:7016 COUNTY ROUTE 10
Mailing Address - City:LISBON
Mailing Address - State:NY
Mailing Address - Zip Code:13658-0176
Mailing Address - Country:US
Mailing Address - Phone:315-393-3227
Mailing Address - Fax:315-393-1322
Practice Address - Street 1:7016 COUNTY ROUTE 10
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:NY
Practice Address - Zip Code:13658-0176
Practice Address - Country:US
Practice Address - Phone:315-393-3227
Practice Address - Fax:315-393-1322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337996364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicare UPIN