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General NPI Number Information
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NPI Number | 1013080613
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Entity Type | Organization
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Legal Business Name | LISA OLDHAM MD LLC
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 05/27/2014
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Provider Practice Location Address
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Address Line | 1300 W BELMONT AVE SUITE 10
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City | CHICAGO
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State | IL
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Zip | 60657-3200
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Country | US
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Telephone | 312-942-0099
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Fax | 773-880-2321
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Provider Business Mailing Address
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Address Line | 1300 W BELMONT AVE SUITE 10
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City | CHICAGO
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State | IL
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Zip | 60657-3200
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Country | US
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Telephone | 312-942-0099
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Fax | 773-880-2321
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. LISA MARIE OLDHAM
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Credential | MD
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Telephone | 312-942-0099
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | 036105494
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License Number State | IL
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