Provider Demographics
NPI:1235177932
Name:ILLIG, LISA CHRISTINE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:CHRISTINE
Last Name:ILLIG
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 1:6500 EXCELSIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4702
Mailing Address - Country:US
Mailing Address - Phone:952-993-0121
Mailing Address - Fax:952-993-1456
Practice Address - Street 1:6500 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4702
Practice Address - Country:US
Practice Address - Phone:952-993-0121
Practice Address - Fax:952-993-1456
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52246207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA209808OtherSOUTHERN HEALTH
VAP00074226OtherMEDICARE PIN
VA005884641Medicaid
VA2959204001OtherCIGNA
VA64758OtherCOMMUNITY HEALTH
VA64758Medicaid
VA00554641Medicaid
VA278633OtherANTHEM SVCS/HEALTHKEEPERS
VA278633Medicaid
VA64758Medicaid
VA209808OtherSOUTHERN HEALTH
VA001963M21Medicare PIN