Provider Demographics
NPI:1164493300
Name:SARDANOPOLI, LISA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:SARDANOPOLI
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 1:100 E LANCASTER AVE
Mailing Address - Street 2:MED OFF BLDG WEST STE 432
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:610-896-7172
Mailing Address - Fax:610-642-2693
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:MED OFF BLDG WEST STE 432
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:610-896-7172
Practice Address - Fax:610-642-2693
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD073683L207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F79220Medicare UPIN
PA049634HK1Medicare PIN
PA232359401OtherMAIN LINE HEALTHCARE
PA001855956Medicaid