Provider Demographics
NPI:1528098985
Name:CHIRCH, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CHIRCH
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 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT OFFICE
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:INFECTIOUS DISEASES
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-2817
Practice Address - Country:US
Practice Address - Phone:860-679-4225
Practice Address - Fax:860-679-1217
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT050203207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1528098985Medicaid
CTD400055897Medicare PIN