Healthcare Provider Details

I. General information

NPI: 1609499615
Provider Name (Legal Business Name): MRS. LISA CHRISTINE BARANSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 S HOSPITAL DR
MURPHYSBORO IL
62966-3333
US

IV. Provider business mailing address

109 CALIFORNIA ST PO BOX 577
CARTERVILLE IL
62918-0577
US

V. Phone/Fax

Practice location:
  • Phone: 618-519-9200
  • Fax: 618-684-2748
Mailing address:
  • Phone: 618-519-9200
  • Fax: 618-985-4635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085.008553
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008553
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: