MEDICARE: DR. LISA S. ETZWILER 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	207PP0204X	Pediatric Emergency Medicine (Emergency Medicine) Physician	102051	MO

General Provider Information

NPI Number	:	1740398593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA S. ETZWILER M.D.

Provider Business Mailing Address
First Line	:	16522 BAXTER FOREST RIDGE DR
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63005-4661
Country	:	US
Telephone Number	:	636-519-1655
Fax Number	:	636-536-4973

Provider Business Practice Location Address
First Line	:	621 S NEW BALLAS RD
Second Line	:	ST. JOHN'S MERCY MEDICAL CENTER, SUITE 6006, TOWER B
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-8232
Country	:	US
Telephone Number	:	314-251-6299
Fax Number	:	314-251-4450

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

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/08/2007

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