Provider Demographics
NPI:1477542769
Name:LISA A SCUDDER DO PA
Entity Type:Organization
Organization Name:LISA A SCUDDER DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SCUDDER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-931-3999
Mailing Address - Street 1:2901 W BUSCH BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-4523
Mailing Address - Country:US
Mailing Address - Phone:813-931-3999
Mailing Address - Fax:813-936-7147
Practice Address - Street 1:2901 W BUSCH BLVD STE 403
Practice Address - Street 2:SUITE 403
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-4566
Practice Address - Country:US
Practice Address - Phone:813-931-3999
Practice Address - Fax:813-931-3999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379545400Medicaid
FL57292AMedicare ID - Type Unspecified
G25491Medicare UPIN