Provider Demographics
NPI: | 1538102561 |
---|---|
Name: | ALDERSON, LISA J (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | LISA |
Middle Name: | J |
Last Name: | ALDERSON |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | LISA |
Other - Middle Name: | J |
Other - Last Name: | ALDERSON |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 3635 VISTA AVE |
Mailing Address - Street 2: | FDT 13TH FLOOR |
Mailing Address - City: | SAINT LOUIS |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63110-2539 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 314-577-8894 |
Mailing Address - Fax: | 314-577-8861 |
Practice Address - Street 1: | 3635 VISTA AVE |
Practice Address - Street 2: | FDT 13TH FLOOR |
Practice Address - City: | SAINT LOUIS |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63110-2539 |
Practice Address - Country: | US |
Practice Address - Phone: | 314-577-8894 |
Practice Address - Fax: | 314-577-8861 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-14 |
Last Update Date: | 2011-09-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 2005029372 | 174400000X, 207RC0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 122060004 | Medicare PIN | |
MO | I62145 | Medicare UPIN |