Basic Information
| Provider Information | |||||||||
| NPI: | 1316959166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TARDIF | ||||||||
| FirstName: | LISE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 QUEEN ST | ||||||||
| Address2: | MEDICAL | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607700 | ||||||||
| FaxNumber: | 5088607990 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 QUEEN ST | ||||||||
| Address2: | MEDICAL | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607700 | ||||||||
| FaxNumber: | 5088607990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 76680 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2198604 | 01 | MA | UNITED HEALTHCARE | OTHER | 347293 | 01 | MA | CIGNA | OTHER | 0006767 | 01 | MA | NHP-GROUP | OTHER | 36702 | 01 | MA | FALLON SELECT | OTHER | 99734901 | 01 | MA | NETWORK HEALTH | OTHER | 0002565 | 01 | MA | NHP | OTHER | 70951 | 01 | MA | HARVARD PILGRIM | OTHER | Y10141 | 01 | MA | BCBS-GROUP | OTHER | 23507 | 01 | MA | CMSP | OTHER | 1300709 | 05 | MA | MEDICAID | 1300709 | 01 | MA | CMSP-GROUP | OTHER |