Provider Demographics
NPI:1508215773
Name:DR LISA SHIVES, MD, PC
Entity Type:Organization
Organization Name:DR LISA SHIVES, MD, PC
Other - Org Name:LISA SHIVES MD SLEEP SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:SHIVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-914-4961
Mailing Address - Street 1:1853 LYNDON RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1644
Mailing Address - Country:US
Mailing Address - Phone:773-914-4961
Mailing Address - Fax:847-827-8706
Practice Address - Street 1:1853 LYNDON RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1644
Practice Address - Country:US
Practice Address - Phone:773-914-4961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-08
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1740322825OtherNPI
ILK35681Medicare PIN