Provider Demographics
NPI:1285731075
Name:POWELL, LISA G (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:G
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:G
Other - Last Name:GILLIAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-6850
Mailing Address - Fax:417-269-5830
Practice Address - Street 1:3850 S NATIONAL AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-269-6850
Practice Address - Fax:417-269-5830
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5695207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
18402OtherBLUE CROSS OF MO
MO202409025Medicaid
18402OtherBLUE CROSS OF MO
A11634Medicare UPIN
P00399773Medicare PIN
007012043Medicare PIN
969915133Medicare PIN