Healthcare Provider Details

I. General information

NPI: 1447256680
Provider Name (Legal Business Name): FREDERIC ELIOT LISS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MAIN ST
PHOENIXVILLE PA
19460-3810
US

IV. Provider business mailing address

833 CHESTNUT ST SUITE 1402
PHILADELPHIA PA
19107-4414
US

V. Phone/Fax

Practice location:
  • Phone: 610-935-1120
  • Fax: 610-935-5507
Mailing address:
  • Phone: 800-321-9999
  • Fax: 267-339-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD036317E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberMD036317E
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MA09448300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: