Provider Demographics
NPI:1720255987
Name:ANDREA C LIGHTBOURN MD PLLC
Entity Type:Organization
Organization Name:ANDREA C LIGHTBOURN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LIGHTBOURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-809-3530
Mailing Address - Street 1:29600 NORTHWESTERN HWY
Mailing Address - Street 2:104
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1016
Mailing Address - Country:US
Mailing Address - Phone:248-809-3530
Mailing Address - Fax:248-327-6082
Practice Address - Street 1:29600 NORTHWESTERN HWY
Practice Address - Street 2:104
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1016
Practice Address - Country:US
Practice Address - Phone:248-809-3530
Practice Address - Fax:248-327-6082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048299174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4408457Medicaid
0N44020Medicare PIN