Healthcare Provider Details

I. General information

NPI: 1720087356
Provider Name (Legal Business Name): JACK S LISSAUER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 PARK EAST DR SUITE 100
BEACHWOOD OH
44122-4339
US

IV. Provider business mailing address

3700 PARK EAST DR SUITE 100
BEACHWOOD OH
44122-4339
US

V. Phone/Fax

Practice location:
  • Phone: 216-593-7700
  • Fax: 216-593-7190
Mailing address:
  • Phone: 216-593-7700
  • Fax: 216-593-7190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35038212L
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: