Provider Demographics
NPI:1801993290
Name:MENACHERY, LISSY KOCHUPLACKAL (MD)
Entity type:Individual
Prefix:DR
First Name:LISSY
Middle Name:KOCHUPLACKAL
Last Name:MENACHERY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:4500 STUART ST
Mailing Address - Street 2:MONCRIEF ARMY HOSPITAL ATTN MCXL-PQ (CREDENTIALS)
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29207-5700
Mailing Address - Country:US
Mailing Address - Phone:803-751-2618
Mailing Address - Fax:803-751-2689
Practice Address - Street 1:4500 STUART STREET
Practice Address - Street 2:MONCRIEF ARMY HOSPITAL ATTN MCXL-PQ (CREDENTIALS)
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29207-5700
Practice Address - Country:US
Practice Address - Phone:803-751-2618
Practice Address - Fax:803-751-2689
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
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Provider Licenses
StateLicense IDTaxonomies
SC15188207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCVAD 000Medicare UPIN