Healthcare Provider Details

I. General information

NPI: 1891118667
Provider Name (Legal Business Name): LYCOMING PHYSICAL MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 E 3RD ST
WILLIAMSPORT PA
17701-5411
US

IV. Provider business mailing address

1111 E 3RD ST
WILLIAMSPORT PA
17701-5411
US

V. Phone/Fax

Practice location:
  • Phone: 570-916-4897
  • Fax: 570-322-8100
Mailing address:
  • Phone: 570-916-4897
  • Fax: 570-322-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD045007L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberMD070043L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC004453L
License Number StatePA

VIII. Authorized Official

Name: DR. MARK ALLEN HAMPTON
Title or Position: CEO
Credential: D.C.
Phone: 570-916-4897