Healthcare Provider Details

I. General information

NPI: 1831478049
Provider Name (Legal Business Name): LIGHTHOUSE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 EASTERLY PKWY SUITE 1
STATE COLLEGE PA
16801-6301
US

IV. Provider business mailing address

311 E. PLEASANT VALLEY BLVD.
ALTOONA PA
16602
US

V. Phone/Fax

Practice location:
  • Phone: 814-308-8456
  • Fax: 814-308-8728
Mailing address:
  • Phone: 814-943-1271
  • Fax: 814-940-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD044867E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD438515
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberOS015480
License Number StatePA

VIII. Authorized Official

Name: JOHN H. JOHNSON
Title or Position: CEO/OWNER
Credential: MD
Phone: 814-943-1271