Provider Demographics
NPI:1851394563
Name:BOR, LISA RUTTENBERG (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RUTTENBERG
Last Name:BOR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 GREYSTONE COMM BLVD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-2660
Mailing Address - Country:US
Mailing Address - Phone:205-745-3660
Mailing Address - Fax:205-745-3649
Practice Address - Street 1:2823 GREYSTONE COMM BLVD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242
Practice Address - Country:US
Practice Address - Phone:205-745-3660
Practice Address - Fax:205-745-3649
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH1468174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7357418OtherAETNA
AL51514151OtherBLUE CROSS OF ALABAMA
AL7357418OtherAETNA
AL51514151OtherBLUE CROSS OF ALABAMA
AL6122470001Medicare NSC