Basic Information
| Provider Information | |||||||||
| NPI: | 1417485541 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LGH PROFESSIONAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 295 VARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789376000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 295 VARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789376000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | WYMAN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9789376034 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CIRCLE HEALTH PHYSICIANS, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | MS, FACHE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.