Provider Demographics
NPI:1497731269
Name:RUTSTEIN, LISA A (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:RUTSTEIN
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 1:12 HIGH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7689
Mailing Address - Country:US
Mailing Address - Phone:207-795-2935
Mailing Address - Fax:207-795-2319
Practice Address - Street 1:12 HIGH ST STE 205
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7689
Practice Address - Country:US
Practice Address - Phone:207-795-2935
Practice Address - Fax:207-795-2319
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD15538208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME277770099Medicaid
MEP00027272OtherRR MEDICARE
NH30203950Medicaid
MEMM997904Medicare PIN
MEMM997901Medicare PIN
MEHX3147Medicare PIN
ME277770099Medicaid