MEDICARE: LISA BURBAGE

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	302R00000X	Health Maintenance Organization		SC

General Provider Information

NPI Number	:	1174021265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA BURBAGE

Provider Business Mailing Address
First Line	:	14 LOCKWOOD DR APT 12G
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29401-1138
Country	:	US
Telephone Number	:	843-442-8909
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 LOCKWOOD DR APT 12G
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29401-1138
Country	:	US
Telephone Number	:	843-442-8909
Fax Number	:

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

Provider Enumeration Date	:	01/24/2018
Last Update Date	:	01/24/2018

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Directions to “ LISA BURBAGE ” Practice Location

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