Provider Demographics
NPI:1578086146
Name:EDWARD J. LIS, JR, DO, PLLC
Entity Type:Organization
Organization Name:EDWARD J. LIS, JR, DO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/CODING
Authorized Official - Prefix:MS
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WISNIEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:248-872-8001
Mailing Address - Street 1:PO BOX 1855
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48347-1855
Mailing Address - Country:US
Mailing Address - Phone:248-872-8001
Mailing Address - Fax:248-673-8079
Practice Address - Street 1:17200 SILVER PKWY
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-4437
Practice Address - Country:US
Practice Address - Phone:248-872-8001
Practice Address - Fax:248-872-8001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014456207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty