Provider Demographics
NPI: | 1245207695 |
---|---|
Name: | HUGHES, LISA A (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | LISA |
Middle Name: | A |
Last Name: | HUGHES |
Suffix: | |
Gender: | F |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 2513 MOMENTUM PL |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60689-5325 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 231-935-6080 |
Mailing Address - Fax: | 231-935-6081 |
Practice Address - Street 1: | 217 S MADISON STREET |
Practice Address - Street 2: | |
Practice Address - City: | TRAVERSE CITY |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49684-2320 |
Practice Address - Country: | US |
Practice Address - Phone: | 231-392-8400 |
Practice Address - Fax: | 231-935-7888 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-03-03 |
Last Update Date: | 2021-03-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 011303 | 207RH0003X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 3363824 | Medicaid | |
MI | LH011303 | Other | BLUE CROSS LICENSE STATE |
MI | 115800635 | Other | RR MEDICARE |
MI | 6408244 | Other | CIGNA |
MI | 115800635 | Other | RR MEDICARE |
MI | G55771 | Medicare UPIN |