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General NPI Number Information
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NPI Number | 1801995766
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Entity Type | Organization
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Legal Business Name | TRI-STATE UROLOGY
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 01/18/2008
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Provider Practice Location Address
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Address Line | 16844 SAINT CLAIR AVE
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City | EAST LIVERPOOL
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State | OH
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Zip | 43920-4277
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Country | US
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Telephone | 330-385-1770
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Fax | 724-728-9722
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Provider Business Mailing Address
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Address Line | 1 PEARTREE WAY
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City | BEAVER
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State | PA
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Zip | 15009-1954
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Country | US
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Telephone | 724-728-4224
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Fax | 724-728-9722
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Authorized Official
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Title or Position | DOCTOR
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Name | MR. MICHAEL LANE LUSTBADER
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Credential | M.D.
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Telephone | 724-728-4224
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | MD031897E
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License Number State | PA
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