Provider Demographics
NPI:1952371338
Name:LIS, EDWARD J JR (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:LIS
Suffix:JR
Gender:M
Credentials:DO
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Mailing Address - Street 1:6310 SASHABAW RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2270
Mailing Address - Country:US
Mailing Address - Phone:248-620-2325
Mailing Address - Fax:248-620-2326
Practice Address - Street 1:6310 SASHABAW RD
Practice Address - Street 2:SUITE A
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2270
Practice Address - Country:US
Practice Address - Phone:248-620-2325
Practice Address - Fax:248-620-2326
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MI5101014456207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4623098Medicaid
MI4623098Medicaid