Provider Demographics
NPI:1649490400
Name:FLAHERTY, LISA (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FLAHERTY
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 1:408 NEWBOLD RD
Mailing Address - Street 2:
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-2851
Mailing Address - Country:US
Mailing Address - Phone:215-884-2645
Mailing Address - Fax:
Practice Address - Street 1:57 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-2799
Practice Address - Country:US
Practice Address - Phone:508-825-8270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220403207PH0002X
DEC2-0008522207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1649490400Medicaid
D80321Medicare UPIN
DE003351D18Medicare PIN