Provider Demographics
NPI:1255336160
Name:HANNER-ROBINSON, LISA J (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:HANNER-ROBINSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:J
Other - Last Name:JERRELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1535 S. PIAZZA DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5578
Mailing Address - Country:US
Mailing Address - Phone:812-334-2772
Mailing Address - Fax:812-323-7347
Practice Address - Street 1:1535 S. PIAZZA DRIVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5578
Practice Address - Country:US
Practice Address - Phone:812-334-2772
Practice Address - Fax:812-323-7347
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052568A207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200284000Medicaid
IN252630GMedicare PIN
H00651Medicare UPIN
IN177560EMedicare ID - Type Unspecified