=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023273489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAMARA LISS MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2008
-----------------------------------------------------
Last Update Date | 09/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 MEADOWS RD SUITE 103
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33486-2346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-347-9044
-----------------------------------------------------
Fax | 561-347-9043
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 273253
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33427-3253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-347-9044
-----------------------------------------------------
Fax | 561-347-9043
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TAMARA LISS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-347-9044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------