=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245289834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MARIE MACCORMACK MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2006
-----------------------------------------------------
Last Update Date | 11/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4231 W 16TH AVE
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80204-1335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-629-3721
-----------------------------------------------------
Fax | 303-629-2192
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1241 W MINERAL AVE SUITE 100
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80120-5685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-759-0854
-----------------------------------------------------
Fax | 303-759-0864
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | A68040
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 36900
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------