1982608824 NPI number — DR. MARK D LISBERGER M.D.

Table of content: DR. MARK D LISBERGER M.D. (NPI 1982608824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982608824 NPI number — DR. MARK D LISBERGER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LISBERGER
Provider First Name:
MARK
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982608824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1999 SPROUL RD
Provider Second Line Business Mailing Address:
STE 21
Provider Business Mailing Address City Name:
BROOMALL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19008-3508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-353-6400
Provider Business Mailing Address Fax Number:
610-356-1204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1999 SPROUL RD
Provider Second Line Business Practice Location Address:
STE 21
Provider Business Practice Location Address City Name:
BROOMALL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19008-3508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-353-6400
Provider Business Practice Location Address Fax Number:
610-356-1204
Provider Enumeration Date:
06/09/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  MD025410E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 58229 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: CF6196 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0009835400001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0031398000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 428350 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".