Provider Demographics
NPI:1982743183
Name:LEBANON SURGICAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:LEBANON SURGICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BAZEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-273-2697
Mailing Address - Street 1:229 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042
Mailing Address - Country:US
Mailing Address - Phone:717-273-2697
Mailing Address - Fax:717-273-0126
Practice Address - Street 1:229 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042
Practice Address - Country:US
Practice Address - Phone:717-273-2697
Practice Address - Fax:717-273-0126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD04154E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011241650001Medicaid
187667FXWMedicare ID - Type Unspecified
B40903Medicare UPIN