MEDICARE: BRUCE MALCOM LIDSTON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	MD016074E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407894173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE MALCOM LIDSTON M.D.

Provider Business Mailing Address
First Line	:	7297 LOVELAND DR
Second Line	:
City	:	HUNTINGDON
State	:	PA
Zip	:	16652-4562
Country	:	US
Telephone Number	:	814-643-0766
Fax Number	:

Provider Business Practice Location Address
First Line	:	1227 WARM SPRINGS AVE
Second Line	:	J.C. BLAIR PHYSICIAN'S BUILDING #301
City	:	HUNTINGDON
State	:	PA
Zip	:	16652-2300
Country	:	US
Telephone Number	:	814-643-0531
Fax Number	:	814-643-6637

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	07/08/2007

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