Provider Demographics
NPI:1326919655
Name:HEADQUARTERS MEDICAL GROUP PA
Entity type:Organization
Organization Name:HEADQUARTERS MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-270-3396
Mailing Address - Street 1:2340 VAN NESS AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-1848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2340 VAN NESS AVE APT 5
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-1848
Practice Address - Country:US
Practice Address - Phone:415-763-5790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-17
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P0301XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationBrain Injury MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P0301XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBrain Injury MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty