Provider Demographics
NPI:1952393589
Name:LISI, MICHELE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:
Last Name:LISI
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 1:224 HARRISON ST
Mailing Address - Street 2:SUITE 601
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3056
Mailing Address - Country:US
Mailing Address - Phone:315-464-6672
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:3RD FLOOR RADIOLOGY
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-6672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227703207U00000X
NY22770312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02224500Medicaid
NY02375079Medicaid
NY02224500Medicaid
NYAA0672Medicare ID - Type UnspecifiedGROUP # PET
NYH79903Medicare UPIN
NYDD4740Medicare ID - Type Unspecified