Healthcare Provider Details

I. General information

NPI: 1144709205
Provider Name (Legal Business Name): LISA EDELMANN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 MADISON AVE FL 2
NEW YORK NY
10029-6508
US

IV. Provider business mailing address

333 LUDLOW ST STE 3
STAMFORD CT
06902-6991
US

V. Phone/Fax

Practice location:
  • Phone: 800-298-6470
  • Fax:
Mailing address:
  • Phone: 475-333-3623
  • Fax: 475-333-3810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License NumberEDELL2
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: