Basic Information
| Provider Information | |||||||||
| NPI: | 1619957917 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ-CONCAGH | ||||||||
| FirstName: | LISSA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3009 N. BALLAS RD | ||||||||
| Address2: | SUITE 365-C | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149910137 | ||||||||
| FaxNumber: | 3149910603 | ||||||||
| Practice Location | |||||||||
| Address1: | 3009 N BALLAS RD | ||||||||
| Address2: | SUITE 365, BLDG C | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149910137 | ||||||||
| FaxNumber: | 3149910603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 10/15/2011 | ||||||||
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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 | 207RN0300X | 108606 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 205957517 | 05 | MO | MEDICAID |