MEDICARE: ANTHONY DAVID LISUZZO PA

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	363A00000X	Physician Assistant	5601010096	MI
2	363A00000X	Physician Assistant	085-005363	IL

General Provider Information

NPI Number	:	1558771543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY DAVID LISUZZO PA

Provider Business Mailing Address
First Line	:	29373 NETWORK PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-1293
Country	:	US
Telephone Number	:	847-390-5900
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 S MILWAUKEE AVE
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-3218
Country	:	US
Telephone Number	:	847-634-1766
Fax Number	:

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

Provider Enumeration Date	:	04/30/2014
Last Update Date	:	05/05/2026

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