Provider Demographics
NPI:1245239789
Name:BIBB, LISA M (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:BIBB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INGALLS DR
Mailing Address - Street 2:PATHOLOGY DEPARTMENT
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-3558
Mailing Address - Country:US
Mailing Address - Phone:708-915-5763
Mailing Address - Fax:708-915-3786
Practice Address - Street 1:1 INGALLS DR
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-3558
Practice Address - Country:US
Practice Address - Phone:708-915-5763
Practice Address - Fax:708-915-3786
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070178207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619826OtherBCBSIL GROUP NUMBER
IL036070178Medicaid
362679690OtherEIN
ILL39712Medicare PIN
IL20017589Medicare ID - Type UnspecifiedRAILROAD MEDICARE NUMBER
1619826OtherBCBSIL GROUP NUMBER
362679690OtherEIN
IL379820Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER