Provider Demographics
NPI:1255428488
Name:LEBANON FAMILY HEALTH SERVICE INC.
Entity type:Organization
Organization Name:LEBANON FAMILY HEALTH SERVICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-273-6741
Mailing Address - Street 1:615 CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-5233
Mailing Address - Country:US
Mailing Address - Phone:717-273-6741
Mailing Address - Fax:717-273-6337
Practice Address - Street 1:615 CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-5233
Practice Address - Country:US
Practice Address - Phone:717-273-6741
Practice Address - Fax:717-273-6337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02821900OtherCAPITAL BLUE CROSS
PA656355OtherHIGHMARK BLUE SHIELD
PA0007146120003Medicaid
PA1503082OtherGATEWAY HEALTH PLAN