MEDICARE: DR. JACK S LISSAUER 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	207RG0100X	Gastroenterology Physician	35038212L	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000127021	OTHER	OH	ANTHEM BCBS & ANTHEM SR
2	000000127021	OTHER	OH	ONE NATION BENEFIT ADMIN.
3	5089882001	OTHER	OH	CIGNA
4	000000127021	OTHER	OH	OHIO OPERATING ENGINEERS
5	4079026	OTHER	OH	AETNA
6	603650	OTHER	OH	UNITED HEALTHCARE
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	P1482889	OTHER	OH	OXFORD INSURANCE
9	R38212	OTHER	OH	APEX & SUMMACARE

General Provider Information

NPI Number	:	1720087356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK S LISSAUER MD

Provider Business Mailing Address
First Line	:	3700 PARK EAST DR
Second Line	:	SUITE 100
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-4339
Country	:	US
Telephone Number	:	216-593-7700
Fax Number	:	216-593-7190

Provider Business Practice Location Address
First Line	:	3700 PARK EAST DR
Second Line	:	SUITE 100
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-4339
Country	:	US
Telephone Number	:	216-593-7700
Fax Number	:	216-593-7190

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	10/24/2007

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Directions to “ DR. JACK S LISSAUER MD” Practice Location

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