Basic Information
| Provider Information | |||||||||
| NPI: | 1548241862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANNEMILLER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1402 BOETTLER RD STE C | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446859584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308990103 | ||||||||
| FaxNumber: | 3308990268 | ||||||||
| Practice Location | |||||||||
| Address1: | 1402 BOETTLER RD STE C | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446859584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308990103 | ||||||||
| FaxNumber: | 3308990268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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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 | 207R00000X | 35067149D | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0786884 | 01 | OH | MEDICARE ID | OTHER | 2157357 | 05 | OH | MEDICAID |