Healthcare Provider Details

I. General information

NPI: 1619957917
Provider Name (Legal Business Name): LISSA LOPEZ-CONCAGH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N NEW BALLAS RD STE 204
SAINT LOUIS MO
63141-6836
US

IV. Provider business mailing address

PO BOX 840185
KANSAS CITY MO
64184-0185
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-0137
  • Fax: 314-991-0603
Mailing address:
  • Phone: 314-991-0137
  • Fax: 314-991-0603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number108606
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: