Provider Demographics
NPI:1104990415
Name:LISENBY PODIATRY
Entity type:Organization
Organization Name:LISENBY PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:HARRISON
Authorized Official - Last Name:LISENBY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:334-671-1441
Mailing Address - Street 1:1550 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3012
Mailing Address - Country:US
Mailing Address - Phone:334-671-1441
Mailing Address - Fax:334-671-1688
Practice Address - Street 1:1550 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3012
Practice Address - Country:US
Practice Address - Phone:334-671-1441
Practice Address - Fax:334-671-1688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA511213E00000X
AL144213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000074869Medicaid
AL74869OtherBCBS
T97724Medicare UPIN
AL0789540001Medicare NSC
AL74869OtherBCBS