Provider Demographics
NPI:1316959166
Name:TARDIF, LISE J (FAMILY PRACTICE)
Entity type:Individual
Prefix:
First Name:LISE
Middle Name:J
Last Name:TARDIF
Suffix:
Gender:F
Credentials:FAMILY PRACTICE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 QUEEN ST
Mailing Address - Street 2:MEDICAL
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2473
Mailing Address - Country:US
Mailing Address - Phone:508-860-7700
Mailing Address - Fax:508-860-7990
Practice Address - Street 1:26 QUEEN ST
Practice Address - Street 2:MEDICAL
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2473
Practice Address - Country:US
Practice Address - Phone:508-860-7700
Practice Address - Fax:508-860-7990
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76680207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2198604OtherUNITED HEALTHCARE
MA347293OtherCIGNA
MA0006767OtherNHP-GROUP
MA36702OtherFALLON SELECT
MA99734901OtherNETWORK HEALTH
MA0002565OtherNHP
MA70951OtherHARVARD PILGRIM
MAY10141OtherBCBS-GROUP
MA23507OtherCMSP
MA1300709Medicaid
MA1300709OtherCMSP-GROUP
MA70951OtherHARVARD PILGRIM
MA36702OtherFALLON SELECT
MA1300709OtherCMSP-GROUP
MA221804Medicare Oscar/Certification
MA0002565OtherNHP