Provider Demographics
NPI:1982673687
Name:MCTAVISH, LISA MICHELE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELE
Last Name:MCTAVISH
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 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:1500 SALEM ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2164
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-379-3312
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044255A207P00000X, 207N00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000990880OtherANTHEM PROVIDER NUMBER - DERMATOLOGY
IN10825581OtherCAQH NUMBER
IN000000877221OtherANTHEM PROVIDER NUMBER - URGENT CARE
IN000000197894OtherANTHEM PROVIDER NUMBER - FAMILY MEDICINE
IN200083620Medicaid
IN9007117OtherPHCS PID NUMBER
IN000000197894OtherANTHEM PROVIDER NUMBER - FAMILY MEDICINE
IN9007117OtherPHCS PID NUMBER
IN080121906Medicare PIN
ING20529Medicare UPIN
IN200083620Medicaid
IN815460AAAAMedicare PIN