Healthcare Provider Details

I. General information

NPI: 1306808019
Provider Name (Legal Business Name): MATTHEW ERIC LISSAUER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

PO BOX 64793
BALTIMORE MD
21264-4793
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6704
  • Fax: 410-328-4124
Mailing address:
  • Phone: 410-328-6704
  • Fax: 410-382-4124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number69621
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberD0063229
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number69621
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberD63229
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: