Provider Demographics
NPI:1871780379
Name:LISBON MEDICAL GROUP
Entity type:Organization
Organization Name:LISBON MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:315-393-3227
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:7016 CTY RT 10
Mailing Address - City:LISBON
Mailing Address - State:NY
Mailing Address - Zip Code:13658-0176
Mailing Address - Country:US
Mailing Address - Phone:315-393-3227
Mailing Address - Fax:315-393-1322
Practice Address - Street 1:7016 CTY RT 10
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:NY
Practice Address - Zip Code:13658-0176
Practice Address - Country:US
Practice Address - Phone:315-393-3227
Practice Address - Fax:315-393-1322
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LISBON MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000374363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00637903Medicaid