Basic Information
| Provider Information | |||||||||
| NPI: | 1003816075 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISBERG | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | NATHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 CAMPUS DR | ||||||||
| Address2: | #10 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635592171 | ||||||||
| FaxNumber: | 7636949000 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 OAKDALE AVE N | ||||||||
| Address2: | |||||||||
| City: | ROBBINSDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554222926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635592171 | ||||||||
| FaxNumber: | 7636949000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 03/03/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 28413 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | 28413 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085B0100X | 28413 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | 28413 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | 28413 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
ID Information
| ID | Type | State | Issuer | Description | 893072400 | 05 | MN | MEDICAID |