Provider Demographics
NPI:1023025913
Name:WITHROW, LISA ANN (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:WITHROW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:WITHROW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2000 6TH AVE S
Mailing Address - Street 2:STE 201
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-2110
Mailing Address - Country:US
Mailing Address - Phone:205-934-9638
Mailing Address - Fax:205-975-7797
Practice Address - Street 1:2000 6TH AVE S
Practice Address - Street 2:STE 201
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-2110
Practice Address - Country:US
Practice Address - Phone:205-934-9638
Practice Address - Fax:205-975-7797
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27167207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1023025913Medicaid
AL510-41731OtherBLUE CROSS BLUE SHIELD OF ALABAMA
1023025913Medicare NSC
ALI57380Medicare UPIN
AL1023025913Medicaid