Healthcare Provider Details

I. General information

NPI: 1821218637
Provider Name (Legal Business Name): LISA MARIE SCHROCK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE DOUTHIT M.D.

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 SOUTH GRAND BLVD. SSM GLENNON CARE - CARDINAL GLENNON CHILDREN'S MEDICAL CENTER
ST. LOUIS MO
63104-1095
US

IV. Provider business mailing address

1465 SOUTH GRAND BLVD. SSM GLENNON CARE - CARDINAL GLENNON CHILDREN'S MEDICAL CENTER
ST. LOUIS MO
63104-1095
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5600
  • Fax:
Mailing address:
  • Phone: 314-577-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number102917
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: