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General NPI Number Information
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NPI Number | 1578086146
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Entity Type | Organization
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Legal Business Name | EDWARD J. LIS, JR, DO, PLLC
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Dates
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Enumeration Date | 07/25/2017
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Last Update Date | 07/25/2017
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Provider Practice Location Address
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Address Line | 17200 SILVER PKWY
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City | FENTON
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State | MI
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Zip | 48430-4437
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Country | US
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Telephone | 248-872-8001
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Fax | 248-872-8001
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Provider Business Mailing Address
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Address Line | PO BOX 1855
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City | CLARKSTON
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State | MI
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Zip | 48347-1855
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Country | US
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Telephone | 248-872-8001
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Fax | 248-673-8079
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Authorized Official
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Title or Position | CREDENTIALING/CODING
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Name | MS. LAUREL A WISNIEWSKI
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Credential | CPC
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Telephone | 248-872-8001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 5101014456
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License Number State | MI
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