1821036500 NPI number — JEROME P LISK MD

Table of content: JEROME P LISK MD (NPI 1821036500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821036500 NPI number — JEROME P LISK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LISK
Provider First Name:
JEROME
Provider Middle Name:
P
Provider Name Prefix Text:
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:
1821036500
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3120 MEDPARK DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76208-6982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-383-1770
Provider Business Mailing Address Fax Number:
877-319-1848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3120 MEDPARK DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76208-6982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-383-1770
Provider Business Practice Location Address Fax Number:
877-319-1848
Provider Enumeration Date:
06/03/2006

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: 2084N0400X , with the licence number:  2004029825 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: R1074 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 366511901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01773741 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 207238106 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 193247 . This is a "BLUE CROSS/BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00890011 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com