Provider Demographics
NPI:1477644151
Name:PISA, MICHELLE DIANE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANE
Last Name:PISA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3215 OVERLOOK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-8578
Mailing Address - Country:US
Mailing Address - Phone:502-228-1175
Mailing Address - Fax:
Practice Address - Street 1:3950 KRESGE WAY STE 308
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4637
Practice Address - Country:US
Practice Address - Phone:502-895-8911
Practice Address - Fax:502-895-8977
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34975207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine