Provider Demographics
NPI:1124220009
Name:LISA M JUDGE M D P A
Entity Type:Organization
Organization Name:LISA M JUDGE M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUTHIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-729-1414
Mailing Address - Street 1:552 TWIN CITIES BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1055
Mailing Address - Country:US
Mailing Address - Phone:850-729-1414
Mailing Address - Fax:850-729-8700
Practice Address - Street 1:552 TWIN CITIES BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1055
Practice Address - Country:US
Practice Address - Phone:850-729-1414
Practice Address - Fax:850-729-8700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN7294OtherRR MEDICARE GROUP PTAN
FLK4521Medicare PIN