Provider Demographics
NPI:1598817207
Name:LISLE MEDICAL ARTS CENTER
Entity Type:Organization
Organization Name:LISLE MEDICAL ARTS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DRISCOLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-692-3844
Mailing Address - Street 1:66 JOHNSON HILL ROAD
Mailing Address - Street 2:POB 338
Mailing Address - City:LISLE
Mailing Address - State:NY
Mailing Address - Zip Code:13797-0338
Mailing Address - Country:US
Mailing Address - Phone:607-692-3844
Mailing Address - Fax:607-692-3846
Practice Address - Street 1:66 JOHNSON HILL ROAD
Practice Address - Street 2:POB 338
Practice Address - City:LISLE
Practice Address - State:NY
Practice Address - Zip Code:13797-0338
Practice Address - Country:US
Practice Address - Phone:607-692-3844
Practice Address - Fax:607-692-3846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113141261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00491447Medicaid
NYB81381Medicare UPIN
NY52823AMedicare PIN