Provider Demographics
NPI:1386665966
Name:EMM, LISA R (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:EMM
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 1:2304 STERN DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4406
Mailing Address - Country:US
Mailing Address - Phone:309-663-0411
Mailing Address - Fax:309-662-2018
Practice Address - Street 1:2304 STERN DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4406
Practice Address - Country:US
Practice Address - Phone:309-663-0411
Practice Address - Fax:309-662-2018
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115642207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216064OtherMEDICARE GROUP #
IL2613OtherMEDICARE GROUP #
IL036115642Medicaid
I57519Medicare UPIN
IL216064OtherMEDICARE GROUP #
IL2613056Medicare PIN