Provider Demographics
NPI:1922033513
Name:HALL, LISA RENEE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:HALL
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 1:3085 LAKECREST CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1707
Mailing Address - Country:US
Mailing Address - Phone:859-258-8600
Mailing Address - Fax:859-258-8610
Practice Address - Street 1:3085 LAKECREST CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1707
Practice Address - Country:US
Practice Address - Phone:859-258-8600
Practice Address - Fax:859-258-8610
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35217207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64000912Medicaid
KY37903705OtherMEDICIAD LAB GRP
GACB5773OtherRR MEDICARE GRP
GA110223769OtherRR MEDICARE PIN
KY4000501OtherMEDICARE LAB GRP
KY0169Medicare PIN
KY37903705OtherMEDICIAD LAB GRP