Basic Information
| Provider Information | |||||||||
| NPI: | 1639187677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISEK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1905 E. HUEBBE PARKWAY | ||||||||
| Address2: | BELOIT HEALTH SYSTEM INC. | ||||||||
| City: | BELOIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535111842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083642200 | ||||||||
| FaxNumber: | 6083637395 | ||||||||
| Practice Location | |||||||||
| Address1: | 5605 E. ROCKTON ROAD | ||||||||
| Address2: | NORTHPOINTE CLINIC | ||||||||
| City: | ROSCOE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610737601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155254500 | ||||||||
| FaxNumber: | 8155254505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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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 | 036097909 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 38216-020 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1639187677 | 05 | WI | MEDICAID | 036097909 | 05 | IL | MEDICAID | 11765 | 01 | DEAN HEALTH PLAN HMO | OTHER |