1720087356 NPI number — DR. JACK S LISSAUER MD

Table of content: DR. JACK S LISSAUER MD (NPI 1720087356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720087356 NPI number — DR. JACK S LISSAUER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LISSAUER
Provider First Name:
JACK
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1720087356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3700 PARK EAST DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BEACHWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122-4339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-593-7700
Provider Business Mailing Address Fax Number:
216-593-7190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3700 PARK EAST DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BEACHWOOD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44122-4339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-593-7700
Provider Business Practice Location Address Fax Number:
216-593-7190
Provider Enumeration Date:
07/15/2005

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: 207RG0100X , with the licence number:  35038212L , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000127021 . This is a "ANTHEM BCBS & ANTHEM SR" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000127021 . This is a "ONE NATION BENEFIT ADMIN." identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 5089882001 . This is a "CIGNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000127021 . This is a "OHIO OPERATING ENGINEERS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 4079026 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 603650 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0307699 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P1482889 . This is a "OXFORD INSURANCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: R38212 . This is a "APEX & SUMMACARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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