Healthcare Provider Details

I. General information

NPI: 1841246048
Provider Name (Legal Business Name): LISA A BRANDENBURGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2564 NW EDENBOWER BLVD SUITE 126
ROSEBURG OR
97471-8821
US

IV. Provider business mailing address

2750 W HARVARD AVE
ROSEBURG OR
97471-2608
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-2223
  • Fax: 541-672-5828
Mailing address:
  • Phone: 541-673-8988
  • Fax: 541-672-8103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD26928
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberMD26928
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: