Healthcare Provider Details

I. General information

NPI: 1104893114
Provider Name (Legal Business Name): PHILIP ANDREW LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 1ST AVE NE
CEDAR RAPIDS IA
52402-5433
US

IV. Provider business mailing address

PO BOX 1408
CEDAR RAPIDS IA
52406-1408
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-3993
  • Fax: 319-364-0116
Mailing address:
  • Phone: 319-365-3993
  • Fax: 319-364-0116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00053
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier54638
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK BC/BS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: