Provider Demographics
NPI:1205821519
Name:WITHERITE-RIEG, LISA A (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:WITHERITE-RIEG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-6560
Mailing Address - Fax:814-372-2848
Practice Address - Street 1:22 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-7228
Practice Address - Country:US
Practice Address - Phone:814-849-0990
Practice Address - Fax:814-849-0992
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS 008448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001523858-0055Medicaid
PA001523858-0004Medicaid
PAG17361Medicare UPIN