Provider Demographics
NPI:1336349240
Name:CRAIG H LICHTBLAU MD PA
Entity Type:Organization
Organization Name:CRAIG H LICHTBLAU MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:H
Authorized Official - Last Name:LICHTBLAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-842-3694
Mailing Address - Street 1:550 NORTHLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-5409
Mailing Address - Country:US
Mailing Address - Phone:561-842-3694
Mailing Address - Fax:561-842-3774
Practice Address - Street 1:550 NORTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-5409
Practice Address - Country:US
Practice Address - Phone:561-842-3694
Practice Address - Fax:561-842-3774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0056279208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0892OtherGROUP PTAN