Healthcare Provider Details

I. General information

NPI: 1295994531
Provider Name (Legal Business Name): LISA MARIE RUPPERT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MADISON AVE 5TH FLOOR
NEW YORK NY
10022-5403
US

IV. Provider business mailing address

515 MADISON AVE 5TH FLOOR
NEW YORK NY
10022-5403
US

V. Phone/Fax

Practice location:
  • Phone: 646-888-1936
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number036125198
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number254560
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: