Provider Demographics
NPI:1841580495
Name:LIGHTHOUSE MEDICAL LLC
Entity type:Organization
Organization Name:LIGHTHOUSE MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-943-1271
Mailing Address - Street 1:311 E. PLEASANT VALLEY BLVD.
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602
Mailing Address - Country:US
Mailing Address - Phone:814-943-1271
Mailing Address - Fax:814-940-8516
Practice Address - Street 1:217 GLENN ST
Practice Address - Street 2:SUITE 401
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2460
Practice Address - Country:US
Practice Address - Phone:301-722-7246
Practice Address - Fax:301-777-2624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-17
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044867E207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3366359 00Medicaid
MDY925OtherCAREFIST BC/BS
MD3366359 00Medicaid