Provider Demographics
NPI:1568431138
Name:CALLIES, LISA S (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:CALLIES
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:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:
Practice Address - Street 1:2800 CHICAGO AVE
Practice Address - Street 2:250
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1318
Practice Address - Country:US
Practice Address - Phone:612-863-4096
Practice Address - Fax:612-863-2132
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32844207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN631307800Medicaid
MN110005674Medicare PIN
MN631307800Medicaid