Provider Demographics
NPI:1326051509
Name:LISI, LOUISE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LOUISE
Middle Name:MARIE
Last Name:LISI
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 1:500 S BROAD ST
Mailing Address - Street 2:SUITE 360
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1613
Mailing Address - Country:US
Mailing Address - Phone:215-685-6769
Mailing Address - Fax:215-685-6732
Practice Address - Street 1:131 E CHELTEN AVE
Practice Address - Street 2:HEALTH CARE CENTER #9
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-2153
Practice Address - Country:US
Practice Address - Phone:215-685-5701
Practice Address - Fax:215-685-5748
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035787E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF08205Medicare UPIN
PALI502448Medicare ID - Type Unspecified