MEDICARE: DR. LISA A DEBERNARDI DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	016004789	IL
2	213EP1101X	Primary Podiatric Medicine Podiatrist	2008030512	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	480014516	OTHER	IL	RAILROAD MEDICARE
5	P01302982	OTHER	MO	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1622982	OTHER	IL	BLUE CROSS / BLUE SHIELD

General Provider Information

NPI Number	:	1043219215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA A DEBERNARDI DPM

Provider Business Mailing Address
First Line	:	5108 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-3113
Country	:	US
Telephone Number	:	314-821-3668
Fax Number	:	888-966-0079

Provider Business Practice Location Address
First Line	:	5108 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-3113
Country	:	US
Telephone Number	:	314-821-3668
Fax Number	:	888-966-0079

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	12/21/2023

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