Provider Demographics
NPI:1336107325
Name:ELLMAN-GRUNTHER, LISA KIM (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:KIM
Last Name:ELLMAN-GRUNTHER
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 11205
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-7205
Mailing Address - Country:US
Mailing Address - Phone:646-854-2003
Mailing Address - Fax:646-493-7299
Practice Address - Street 1:115 BROADWAY
Practice Address - Street 2:STE 1800
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-1652
Practice Address - Country:US
Practice Address - Phone:646-854-2003
Practice Address - Fax:646-493-7299
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MMAO7471600207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8970700Medicaid
NJ8970700Medicaid