Healthcare Provider Details

I. General information

NPI: 1083610968
Provider Name (Legal Business Name): LISA S. PHILLIPS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PORT WASHINGTON BLVD
ROSLYN NY
11576-1353
US

IV. Provider business mailing address

100 PORT WASHINGTON BLVD
ROSLYN NY
11576-1353
US

V. Phone/Fax

Practice location:
  • Phone: 516-627-6624
  • Fax: 516-627-3804
Mailing address:
  • Phone: 516-627-6624
  • Fax: 516-627-3804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number209718
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number209718-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: