MEDICARE: DR. LEA QUITANIA LISOWSKI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	36116636	IL

General Provider Information

NPI Number	:	1669687315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEA QUITANIA LISOWSKI M.D.

Provider Business Mailing Address
First Line	:	10003 US ROUTE 30
Second Line	:
City	:	WATERMAN
State	:	IL
Zip	:	60556-7128
Country	:	US
Telephone Number	:	815-264-3484
Fax Number	:	815-264-8659

Provider Business Practice Location Address
First Line	:	10003 US ROUTE 30
Second Line	:
City	:	WATERMAN
State	:	IL
Zip	:	60556
Country	:	US
Telephone Number	:	815-264-3484
Fax Number	:	815-264-8659

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	05/18/2018

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