Provider Demographics
NPI:1932382595
Name:LIGHTHOUSE MEDICAL, LLC
Entity Type:Organization
Organization Name:LIGHTHOUSE MEDICAL, LLC
Other - Org Name:
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 1:301 E. PLEASANT VALLEY BLVD.
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602
Practice Address - Country:US
Practice Address - Phone:814-944-5835
Practice Address - Fax:814-944-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044867E174400000X
PAMD4385152081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020712560001Medicaid
PAE83725Medicare PIN