Provider Demographics
NPI:1215054192
Name:LYSIAK, ANNA C (MD)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:C
Last Name:LYSIAK
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 1:8001 ROOSEVELT BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-3038
Mailing Address - Country:US
Mailing Address - Phone:215-332-9880
Mailing Address - Fax:215-332-9880
Practice Address - Street 1:8001 ROOSEVELT BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-3038
Practice Address - Country:US
Practice Address - Phone:215-332-9880
Practice Address - Fax:215-332-9880
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038516L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA07089OtherSENIOR PARTNERS
PA47998OtherKEYSTONE MERCY
PA07089OtherHEALTH PARTNERS
PA0009532460001Medicaid
PA0054209001OtherBCBS
PAD70015Medicare UPIN
PA07089OtherHEALTH PARTNERS