Healthcare Provider Details

I. General information

NPI: 1902992340
Provider Name (Legal Business Name): LISA L KISER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA L WILLACKER MD

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 06/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

PO BOX 636256
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-5281
  • Fax: 513-558-5791
Mailing address:
  • Phone: 513-585-5505
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number47728
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35088540
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: