Provider Demographics
NPI:1487644845
Name:LUSK, ALICE S (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:S
Last Name:LUSK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:H
Other - Last Name:ISAACSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2808
Mailing Address - Country:US
Mailing Address - Phone:574-232-3327
Mailing Address - Fax:574-232-3369
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2808
Practice Address - Country:US
Practice Address - Phone:574-232-3327
Practice Address - Fax:574-232-3369
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050252A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200209940Medicaid
IN146470FMedicare ID - Type Unspecified
ING93026Medicare UPIN