MEDICARE: DR. LISA MARIE FAULCON MD

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	2080P0207X	Pediatric Hematology & Oncology Physician	946665	MD

General Provider Information

NPI Number	:	1235336124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA MARIE FAULCON MD

Provider Business Mailing Address
First Line	:	720 RUTLAND AVE
Second Line	:	ROSS 1125, DEPT OF HEMATOLOGY
City	:	BALTIMORE
State	:	MD
Zip	:	21205-2109
Country	:	US
Telephone Number	:	410-955-6132
Fax Number	:

Provider Business Practice Location Address
First Line	:	720 RUTLAND AVE
Second Line	:	ROSS 1125, DEPT OF HEMATOLOGY
City	:	BALTIMORE
State	:	MD
Zip	:	21205-2109
Country	:	US
Telephone Number	:	410-955-6132
Fax Number	:

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

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	12/08/2011

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