Lucilyn Ann Bullock, PA-C
Individual provider Active NPI Medical Physician Assistant · Tallmadge, OH
NPI 1104963552 · NPPES record last updated Mar 30, 2022
Key facts
- NPI
- 1104963552
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Medical Physician Assistant 363AM0700X
- License
- 50-000779 (OH)
- Practice address
- 60 North Ave
Tallmadge, OH 44278-2011 - Phone
- (330) 670-4242
- Fax
- (330) 670-4241
- NPI assigned
- Feb 1, 2007
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 4
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OH
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20090223000283 | OH | Practitioner - Physician Assistant | 6507921756 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 50-000779 | OH | MD | Medical Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Pioneer Physicians Network, Inc. | Current |
Accepting new patients | |
| Pioneer Physicians Network Inc | Current |
Accepting new patients | |
| Crystal Clinic Inc | Past | Accepting new patients |
Locations
3515 Massillon Rd
Ste 300
Green, OH 44685
Phone (234) 271-3353
3300 Greenwich Rd
Unit 8
Norton, OH 44203
Phone (330) 825-7371
Interoperability endpoints
- https://fhir4.healow.com/fhir/r4/BBBCAA
- lbullock22144@summahealth-direct.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | 50-000779 | OH | Yes |
Addresses
Primary practice location
60 North Ave
Tallmadge, OH 44278-2011
Mailing address
60 North Ave
Tallmadge, OH 44278-2011
Phone (330) 630-9726
Other providers in Tallmadge, OH
- Sandra Brotman Domoracki
- Amihya Brown
- Anihya Brown
- Maggie M Brown
- Leah Buck
- Jason M Bursach
- Katelin Marie Byerly
- Humberto Gonzales Caballero
- Amy Eda Cakir
- Michael Adam Carder
All providers in Tallmadge, OH · Medical Physician Assistant in Ohio
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 30, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.