Provider Demographics
NPI:1457432833
Name:THORN, LISA M (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:THORN
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 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:3305 ROUTE 43
Practice Address - Street 2:
Practice Address - City:AVERILL PARK
Practice Address - State:NY
Practice Address - Zip Code:12018
Practice Address - Country:US
Practice Address - Phone:518-674-5797
Practice Address - Fax:518-674-2396
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10002042OtherCDPHP
NY5731176OtherAETNA
NY01397479Medicaid
NY92949OtherGHI/HMO
NY5562A1OtherEMPIRE BC
NYFIDELISOther070129000060
NY000401537006OtherBSNENY
NY383845OtherMVP
NYSENIOR WHOLE HEALTHOther200249
NYFIDELISOther070129000060
NY000401537006OtherBSNENY