Provider Demographics
NPI:1184792616
Name:STAGNER, LISA D (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:STAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:2799 WEST GRAND BOULEVARD
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-2421
Mailing Address - Fax:313-916-9102
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:2799 WEST GRAND BOULEVARD
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-2421
Practice Address - Fax:313-916-9102
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012063207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LS012063OtherCOMMERCIAL-COMMERCIAL NUMBER
LS012063OtherCHAMPUS-CHAMPUS
MI336313611Medicaid
290H264420OtherBLUE CROSS-BLUE CROSS
MI336313611Medicaid
290H264420OtherBLUE CROSS-BLUE CROSS