Provider Demographics
NPI:1063476604
Name:PULLUM, LISA ANN (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:PULLUM
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:5555 GLENWOOD HILLS PKWY SE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2091
Mailing Address - Country:US
Mailing Address - Phone:616-940-2662
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:6896 S GREENVILLE RD STE 100
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-1081
Practice Address - Country:US
Practice Address - Phone:616-754-5036
Practice Address - Fax:616-754-4380
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2021-05-06
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Provider Licenses
StateLicense IDTaxonomies
MI5101013172207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4802689-11Medicaid
7681459OtherAETNA
30230OtherHEALTH PLAN OF MICHIGAN
MI555590041OtherBCBSM
3743669OtherCIGNA
7000027121OtherPRIORITY HEALTH MEDICAID
050067089OtherRAILROAD MEDICARE
MI7000027121OtherPRIORITY HEALTH
MI7000027121OtherPRIORITY HEALTH
MID16000008Medicare PIN