Provider Demographics
NPI:1952321473
Name:LEWISBURG CANCER CENTER LLC
Entity Type:Organization
Organization Name:LEWISBURG CANCER CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-374-8555
Mailing Address - Street 1:1575 N OLD TRL
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-8381
Mailing Address - Country:US
Mailing Address - Phone:570-374-8555
Mailing Address - Fax:570-374-9933
Practice Address - Street 1:75 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-6343
Practice Address - Country:US
Practice Address - Phone:570-374-8555
Practice Address - Fax:570-374-9933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00196120600001Medicaid
PA5018410001Medicare NSC
PA069768Medicare PIN