Provider Demographics
NPI:1831478049
Name:LIGHTHOUSE MEDICAL LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-943-1271
Mailing Address - Street 1:311 E. PLEASANT VALLEY BLVD.
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602
Mailing Address - Country:US
Mailing Address - Phone:814-943-1271
Mailing Address - Fax:814-940-8516
Practice Address - Street 1:253 EASTERLY PKWY
Practice Address - Street 2:SUITE 1
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-6301
Practice Address - Country:US
Practice Address - Phone:814-308-8456
Practice Address - Fax:814-308-8728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044867E207LP2900X
PAMD438515208100000X
PAOS015480208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020712560001Medicaid
PA1020712560001Medicaid