MEDICARE: LISA MICHELLE HOLTSCLAW D.O.

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	207Q00000X	Family Medicine Physician	02001568A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619957164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MICHELLE HOLTSCLAW D.O.

Provider Business Mailing Address
First Line	:	30 W MONROE ST STE 1200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60603-2420
Country	:	US
Telephone Number	:	312-733-9730
Fax Number	:	773-866-8014

Provider Business Practice Location Address
First Line	:	436 E WASHINGTON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46802-3210
Country	:	US
Telephone Number	:	260-209-7111
Fax Number	:	260-222-2835

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

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	06/22/2020

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