Provider Demographics
NPI:1265670749
Name:LIEN, ELLISIV (MD)
Entity Type:Individual
Prefix:
First Name:ELLISIV
Middle Name:
Last Name:LIEN
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:PO BOX 6605
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6605
Mailing Address - Country:US
Mailing Address - Phone:903-592-6000
Mailing Address - Fax:903-592-3224
Practice Address - Street 1:2737 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5413
Practice Address - Country:US
Practice Address - Phone:903-592-6000
Practice Address - Fax:903-592-3224
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1735208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202858101Medicaid
TX8L9112Medicare PIN