Provider Demographics
NPI:1720087356
Name:LISSAUER, JACK S (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:S
Last Name:LISSAUER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3700 PARK EAST DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4339
Mailing Address - Country:US
Mailing Address - Phone:216-593-7700
Mailing Address - Fax:216-593-7190
Practice Address - Street 1:3700 PARK EAST DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4339
Practice Address - Country:US
Practice Address - Phone:216-593-7700
Practice Address - Fax:216-593-7190
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35038212L207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000127021OtherANTHEM BCBS & ANTHEM SR
OH000000127021OtherONE NATION BENEFIT ADMIN.
OH5089882001OtherCIGNA
OH000000127021OtherOHIO OPERATING ENGINEERS
OH4079026OtherAETNA
OH603650OtherUNITED HEALTHCARE
OH0307699Medicaid
OHP1482889OtherOXFORD INSURANCE
OHR38212OtherAPEX & SUMMACARE
OHA75550Medicare UPIN
OHP1482889OtherOXFORD INSURANCE
OHLI0421211Medicare ID - Type UnspecifiedMEDICARE
OHLI0421212Medicare ID - Type UnspecifiedMEDICARE