Healthcare Provider Details

I. General information

NPI: 1619586518
Provider Name (Legal Business Name): LISA K ANDERSON-SHAW APN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MACNEAL TRINITY MEDICAL CETNER 3249 OAK PARK AVENUE
BERWYN IL
60402
US

IV. Provider business mailing address

420 E WATERSIDE DR UNIT 3910
CHICAGO IL
60601-8026
US

V. Phone/Fax

Practice location:
  • Phone: 708-738-9100
  • Fax:
Mailing address:
  • Phone: 312-636-4908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174V00000X
TaxonomyClinical Ethicist
License Number209001980
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: