Provider Demographics
NPI:1629085949
Name:LISNER, BLAINE M (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:M
Last Name:LISNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3707 CHAMBERLAIN LANE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2091
Mailing Address - Country:US
Mailing Address - Phone:502-426-9200
Mailing Address - Fax:502-426-9259
Practice Address - Street 1:3747 DIANN MARIE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241
Practice Address - Country:US
Practice Address - Phone:502-426-9200
Practice Address - Fax:502-426-9259
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY253682084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00230839OtherRAILROAD MEDICARE
279500OtherMEDICARE GROUP
IL036065238 2Medicaid
B28646Medicare UPIN
K14272Medicare PIN
IL036065238 2Medicaid
P00230839OtherRAILROAD MEDICARE