Healthcare Provider Details

I. General information

NPI: 1215054192
Provider Name (Legal Business Name): ANNA C LYSIAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 ROOSEVELT BLVD SUITE 303
PHILADELPHIA PA
19152-3038
US

IV. Provider business mailing address

8001 ROOSEVELT BLVD SUITE 303
PHILADELPHIA PA
19152-3038
US

V. Phone/Fax

Practice location:
  • Phone: 215-332-9880
  • Fax: 215-332-9880
Mailing address:
  • Phone: 215-332-9880
  • Fax: 215-332-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD038516L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: