MEDICARE: LISA MARIE OLDHAM M.D.

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	207VG0400X	Gynecology Physician	036-105494	IL

General Provider Information

NPI Number	:	1689636904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE OLDHAM M.D.

Provider Business Mailing Address
First Line	:	7447 W TALCOTT AVE STE 454
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-3715
Country	:	US
Telephone Number	:	773-631-5767
Fax Number	:

Provider Business Practice Location Address
First Line	:	7447 W TALCOTT AVE STE 454
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-3715
Country	:	US
Telephone Number	:	773-631-5767
Fax Number	:

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

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	10/04/2021

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