Provider Demographics
NPI:1730131475
Name:MILLER, LISA K (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:K
Last Name:MILLER
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 1:1275 E BELVIDERE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2082
Mailing Address - Country:US
Mailing Address - Phone:847-918-1462
Mailing Address - Fax:847-968-4311
Practice Address - Street 1:1275 E BELVIDERE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2082
Practice Address - Country:US
Practice Address - Phone:847-918-1462
Practice Address - Fax:847-968-4311
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI487192085R0202X
IL036-0594092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059409Medicaid
IL202926OtherGROUP PTAN
WI34813100Medicaid
IL212545OtherGROUP PTAN
C43774Medicare UPIN
IL202926015Medicare PIN
WI34813100Medicaid