MEDICARE: LISA C OVERTON

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	SC004492L	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	P00041340	OTHER	PA	MEDICARE RAILROAD ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2134337000	OTHER	PA	10 DIGIT IBC HMO ID
2	10741	OTHER	PA	ELDER HEALTH ID
3	5403600001	OTHER	PA	DMERC SUPPLIER ID
4	001444333	OTHER	PA	HIGH MARK BLUE SHIELD ID
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356397913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA C OVERTON

Provider Business Mailing Address
First Line	:	1940 E WALNUT LN
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19138-1312
Country	:	US
Telephone Number	:	215-548-2113
Fax Number	:	215-548-3009

Provider Business Practice Location Address
First Line	:	1940 E WALNUT LN
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19138-1312
Country	:	US
Telephone Number	:	215-548-2113
Fax Number	:	215-548-3009

Authorized Official
Title or Position	:	PODIATRIST
Name	:	DR. LISA CAROL OVERTON
Credential	:	D.P.M.
Telephone Number	:	215-548-2010

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	09/02/2011

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Directions to “LISA C OVERTON ” Practice Location

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