Provider Demographics
NPI:1265418271
Name:RIZACK, LILLIE (CNM)
Entity type:Individual
Prefix:
First Name:LILLIE
Middle Name:
Last Name:RIZACK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6938 WEATHAM ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2519
Mailing Address - Country:US
Mailing Address - Phone:267-471-1315
Mailing Address - Fax:
Practice Address - Street 1:34TH AND CIVIC CENTER BLVD
Practice Address - Street 2:THE CHILDREN'S HOSPITAL OF PHILADELPHIA
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:267-425-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW008589L367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001814185Medicaid
PA091904SK5Medicare ID - Type Unspecified
PAP16910Medicare UPIN