# GEORGE A LIGHTBOURN MD PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1083887822
- **Authorized official:** DR. GEROGE A LIGHTBOURN M.D. (PRESIDENT)
- **Authorized official phone:** (248) 353-6599

## Contact information

- **Practice address:** 29600 NORTHWESTERN HWY, SUITE 104, SOUTHFIELD, MI 48034-1016
- **Practice address phone:** (248) 353-6599
- **Practice address fax:** (248) 353-6566
- **Mailing address:** PO BOX 937, SOUTHFIELD, MI 48037-0937
- **Mailing address phone:** (248) 353-6599
- **Mailing address fax:** (248) 353-6566

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208800000X | Urology Physician | — | NULL | Yes |
| 208800000X | Urology Physician | — | — | Yes |

## Other

- **Enumeration date:** 04/11/2008
- **Last updated:** 12/11/2013

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 101346646 | — | MI |
| 01 | — | 1123970001 | WELLNESS PLAN | — |
| 01 | — | 3408257131 | BLUE CROSS BLUE SHIELD | — |