Basic Information
| Provider Information | |||||||||
| NPI: | 1255321576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISY | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3515 MASSILLON RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446856400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308999350 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4880 S MAIN ST | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443194474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306442700 | ||||||||
| FaxNumber: | 3306341329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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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 | 207R00000X | 35-075097 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 35-075097 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2225372 | 05 | OH | MEDICAID |