Healthcare Provider Details

I. General information

NPI: 1346215126
Provider Name (Legal Business Name): LISA RAACKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE STE 613
HACKENSACK NJ
07601-1962
US

IV. Provider business mailing address

20 PROSPECT AVE STE 613
HACKENSACK NJ
07601-1962
US

V. Phone/Fax

Practice location:
  • Phone: 201-336-8111
  • Fax: 201-336-8445
Mailing address:
  • Phone: 201-336-8111
  • Fax: 201-336-8445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1677921
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08360000
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier01590596
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 2
Identifier110166628
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerRR MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: