Basic Information
| Provider Information | |||||||||
| NPI: | 1205987021 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIS | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 GRAMERCY PL | ||||||||
| Address2: | |||||||||
| City: | GLEN ROCK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074522309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014457478 | ||||||||
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| Practice Location | |||||||||
| Address1: | OLMMC, DEPT. OF MEDICINE | ||||||||
| Address2: | 600 EAST 233RD STREET | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189209889 | ||||||||
| FaxNumber: | 7189209036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 04/02/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 165062 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 165062 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 165062 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 01454113 | 05 | NY | MEDICAID |