Provider Demographics
NPI:1124130638
Name:MARRACHE, LISA T (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:T
Last Name:MARRACHE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 SILVER ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901
Mailing Address - Country:US
Mailing Address - Phone:207-872-0866
Mailing Address - Fax:207-872-8098
Practice Address - Street 1:109 SILVER ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901
Practice Address - Country:US
Practice Address - Phone:207-872-0866
Practice Address - Fax:207-872-8098
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME132890099Medicaid
ME027974OtherANTHEM
ME027974OtherANTHEM
MESX1407Medicare PIN