Basic Information
| Provider Information | |||||||||
| NPI: | 1477542769 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LISA A SCUDDER DO PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 W BUSCH BLVD | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336184523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139313999 | ||||||||
| FaxNumber: | 8139367147 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 W BUSCH BLVD STE 403 | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336184566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139313999 | ||||||||
| FaxNumber: | 8139313999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 10/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | SCUDDER | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8139313999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS7188 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 379545400 | 05 | FL | MEDICAID |