Provider Demographics
NPI:1689762809
Name:BURKE, LISA K (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:BURKE
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 60099
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0099
Mailing Address - Country:US
Mailing Address - Phone:704-543-6636
Mailing Address - Fax:704-541-9476
Practice Address - Street 1:9550 ROCKY RIVER RD STE 150
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-9592
Practice Address - Country:US
Practice Address - Phone:704-316-5281
Practice Address - Fax:704-316-5283
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035452207P00000X
NC39733207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1689762809Medicaid
NC5910484Medicaid
SCNC2533Medicaid
NC2023277KMedicare PIN
NC2023277DMedicare PIN
NC2023277JMedicare PIN
NC2023277CMedicare PIN
NC5910484Medicaid
NC2023277EMedicare PIN
NC1689762809Medicaid
NC2023277MMedicare PIN
NC2023277GMedicare PIN
SCNC2533Medicaid
NC2023277NMedicare PIN
NC2023277AMedicare PIN