MEDICARE: JEFFREY LAWRENCE LISIECKI 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	208200000X	Plastic Surgery Physician	S9341	TX
2	390200000X	Student in an Organized Health Care Education/Training Program	4301107909	MI
3	208200000X	Plastic Surgery Physician	314856	NY

General Provider Information

NPI Number	:	1447630199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY LAWRENCE LISIECKI MD

Provider Business Mailing Address
First Line	:	737 PARK AVE APT 1C
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-4264
Country	:	US
Telephone Number	:	212-680-4626
Fax Number	:

Provider Business Practice Location Address
First Line	:	737 PARK AVE APT 1C
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-4264
Country	:	US
Telephone Number	:	212-680-4626
Fax Number	:

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

Provider Enumeration Date	:	06/08/2015
Last Update Date	:	07/28/2022

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