MEDICARE: LISA M CORAM DO

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	2084P0800X	Psychiatry Physician	5101020468	MI

General Provider Information

NPI Number	:	1215197926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M CORAM DO

Provider Business Mailing Address
First Line	:	2300 HAGGERTY RD STE 2160
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-2192
Country	:	US
Telephone Number	:	248-859-2457
Fax Number	:	248-859-2473

Provider Business Practice Location Address
First Line	:	2300 HAGGERTY RD STE 2160
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-2192
Country	:	US
Telephone Number	:	248-859-2457
Fax Number	:	248-859-2473

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

Provider Enumeration Date	:	06/16/2008
Last Update Date	:	04/04/2019

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Directions to “ LISA M CORAM DO” Practice Location

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