Provider Demographics
NPI:1851374912
Name:SHURBA, LISA M (DIETICIAN REGISTERED)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:SHURBA
Suffix:
Gender:F
Credentials:DIETICIAN REGISTERED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W NORTH AVE
Mailing Address - Street 2:DIETARY DEPARTMENT
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1612
Mailing Address - Country:US
Mailing Address - Phone:708-681-3200
Mailing Address - Fax:
Practice Address - Street 1:701 W NORTH AVE
Practice Address - Street 2:DIETARY DEPARTMENT
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1612
Practice Address - Country:US
Practice Address - Phone:708-681-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL884400133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL94592 201896Medicare PIN
ILOTH000Medicare UPIN
IL215025001Medicare PIN
IL516846001Medicare PIN