Provider Demographics
NPI:1841261013
Name:CRUTCHER, LISA D (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:D
Last Name:CRUTCHER
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 1:1830 MEDITERRANEAN DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3144
Mailing Address - Country:US
Mailing Address - Phone:815-306-2700
Mailing Address - Fax:815-306-2715
Practice Address - Street 1:1830 MEDITERRANEAN DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3144
Practice Address - Country:US
Practice Address - Phone:815-306-2700
Practice Address - Fax:815-306-2715
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL920540044OtherMEDICARE PTAN (INDIVIDUAL)
IL036104449Medicaid
IL920540OtherMEDICARE PTAN (GROUP)
ILK51243Medicare PIN
ILIL2556007Medicare PIN
IL920540044OtherMEDICARE PTAN (INDIVIDUAL)