Healthcare Provider Details

I. General information

NPI: 1093816266
Provider Name (Legal Business Name): LISA MARIE EDGERTON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

114 NE 107TH ST
MIAMI SHORES FL
33161-7032
US

V. Phone/Fax

Practice location:
  • Phone: 517-253-6320
  • Fax: 517-253-6321
Mailing address:
  • Phone: 786-390-8684
  • Fax: 305-654-5270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number5101013599
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101013599
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberOS 8636
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: