Basic Information
Provider Information | |||||||||
NPI: | 1194933861 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EDSALL | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | CSEH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 CONCOURSE BLVD | ||||||||
Address2: | SUITE 190 | ||||||||
City: | GLEN ALLEN | ||||||||
State: | VA | ||||||||
PostalCode: | 230595643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8045494030 | ||||||||
FaxNumber: | 8045494032 | ||||||||
Practice Location | |||||||||
Address1: | 320A CHARLES H DIMMOCK PKWY | ||||||||
Address2: | SUITE 7 | ||||||||
City: | COLONIAL HEIGHTS | ||||||||
State: | VA | ||||||||
PostalCode: | 238342917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8045267364 | ||||||||
FaxNumber: | 8045267394 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2007 | ||||||||
LastUpdateDate: | 03/15/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 0101241020 | VA | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   | 390200000X | 0101241020 | VA | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.