Provider Demographics
NPI:1184672396
Name:YOUNG, LISA ROSENTHAL (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ROSENTHAL
Last Name:YOUNG
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 PENN SQ FL 9
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3377
Mailing Address - Country:US
Mailing Address - Phone:267-425-9412
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:3500 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-1000
Practice Address - Fax:267-425-9299
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-079881207R00000X, 207RP1001X, 208000000X, 2080P0214X
TN47924207RP1001X, 2080P0214X
PAMD4667542080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64113665Medicaid
OH2592672Medicaid
IN200539670Medicaid
OH2592672Medicaid
KY64113665Medicaid