Provider Demographics
NPI:1467443606
Name:MOUNT, LISA E (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:E
Last Name:MOUNT
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 3439
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-0439
Mailing Address - Country:US
Mailing Address - Phone:843-839-4447
Mailing Address - Fax:
Practice Address - Street 1:3361 HIGHWAY 9 E
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7826
Practice Address - Country:US
Practice Address - Phone:843-497-5929
Practice Address - Fax:866-778-9612
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20187207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC201873Medicaid
SCAA87024560Medicare PIN
SCG002337730Medicare PIN
P00104913Medicare PIN