Provider Demographics
NPI:1962674820
Name:BURCKHARTZMEYER, LISA JEAN (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:JEAN
Last Name:BURCKHARTZMEYER
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 1:2214 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604
Mailing Address - Country:US
Mailing Address - Phone:309-680-7634
Mailing Address - Fax:309-676-5506
Practice Address - Street 1:228 NE JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602
Practice Address - Country:US
Practice Address - Phone:309-671-8000
Practice Address - Fax:309-671-4695
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL0361293702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036129370Medicaid