Healthcare Provider Details

I. General information

NPI: 1972876472
Provider Name (Legal Business Name): LYCOMING PHYSICIAN SERVICES,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 N SUSQUEHANNA TRL
SHAMOKIN DAM PA
17876-9113
US

IV. Provider business mailing address

3040 N SUSQUEHANNA TRL P.O. BOX 129
SHAMOKIN DAM PA
17876-9113
US

V. Phone/Fax

Practice location:
  • Phone: 570-743-1703
  • Fax: 570-743-1728
Mailing address:
  • Phone: 717-743-1703
  • Fax: 570-743-1728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ALBERT JOHN LAGERMAN JR.
Title or Position: ADMINISTRATOR
Credential: MBA
Phone: 570-743-1703