Healthcare Provider Details

I. General information

NPI: 1265418271
Provider Name (Legal Business Name): LILLIE RIZACK CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34TH AND CIVIC CENTER BLVD THE CHILDREN'S HOSPITAL OF PHILADELPHIA
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

6938 WEATHAM ST
PHILADELPHIA PA
19119-2519
US

V. Phone/Fax

Practice location:
  • Phone: 267-425-6900
  • Fax:
Mailing address:
  • Phone: 267-471-1315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberMW008589L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: