Provider Demographics
NPI:1033154794
Name:FAIRCHILD, LISA D (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:FAIRCHILD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 HIGHWAY 61 N
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8211
Mailing Address - Country:US
Mailing Address - Phone:601-883-5000
Mailing Address - Fax:
Practice Address - Street 1:2100 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8211
Practice Address - Country:US
Practice Address - Phone:601-883-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16733208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1484041Medicaid
MS00123219Medicaid
MS7004163OtherAETNA
LA1484041Medicaid
MS370022589Medicare PIN
MS00123219Medicaid
MS370000365Medicare PIN