Provider Demographics
NPI:1639187677
Name:LISEK, ROBERT R (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:LISEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1905 E. HUEBBE PARKWAY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC.
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-363-7395
Practice Address - Street 1:5605 E. ROCKTON ROAD
Practice Address - Street 2:NORTHPOINTE CLINIC
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7601
Practice Address - Country:US
Practice Address - Phone:815-525-4500
Practice Address - Fax:815-525-4505
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036097909207R00000X
WI38216-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639187677Medicaid
IL036097909Medicaid
11765OtherDEAN HEALTH PLAN HMO
IL036097909Medicaid