Provider Demographics
NPI:1992857395
Name:LYCOMING NEUROSURGICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:LYCOMING NEUROSURGICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODWAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:RAJJOUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-326-2035
Mailing Address - Street 1:904 CAMPBELL ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-3166
Mailing Address - Country:US
Mailing Address - Phone:570-326-2035
Mailing Address - Fax:570-326-9220
Practice Address - Street 1:904 CAMPBELL ST
Practice Address - Street 2:SUITE 104
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3166
Practice Address - Country:US
Practice Address - Phone:570-326-2035
Practice Address - Fax:570-326-9220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038209L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1528033651OtherDR RODWAN RAJJOUB NPI
PA0008460030003Medicaid
PA106188Medicare PIN
PAB36674Medicare UPIN