MEDICARE: LISA ANN MEDVETZ 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	207QA0401X	Addiction Medicine (Family Medicine) Physician	MD060721-L	PA
2	208600000X	Surgery Physician	51460	KY
3	208600000X	Surgery Physician	MD060721L	PA
4	208600000X	Surgery Physician	M-13032	ID
5	208600000X	Surgery Physician	25MA06954000	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	113499	OTHER	PA	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467451823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ANN MEDVETZ MD

Provider Business Mailing Address
First Line	:	500 GROVE ST
Second Line	:	SUITE 100
City	:	HADDON HEIGHTS
State	:	NJ
Zip	:	08035-1761
Country	:	US
Telephone Number	:	856-796-9200
Fax Number	:	856-796-9397

Provider Business Practice Location Address
First Line	:	1113 HOSPITAL DR
Second Line	:	SUITE 100
City	:	WILLINGBORO
State	:	NJ
Zip	:	08046-1103
Country	:	US
Telephone Number	:	609-835-5821
Fax Number	:	609-835-5827

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

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	09/01/2023

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Directions to “ LISA ANN MEDVETZ MD” Practice Location

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