Basic Information
Provider Information | |||||||||
NPI: | 1689786154 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LISCOW | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 930 BLUE STAR HWY | ||||||||
Address2: |   | ||||||||
City: | SOUTH HAVEN | ||||||||
State: | MI | ||||||||
PostalCode: | 490907758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2696371115 | ||||||||
FaxNumber: | 2696391314 | ||||||||
Practice Location | |||||||||
Address1: | 930 BLUE STAR HWY | ||||||||
Address2: |   | ||||||||
City: | SOUTH HAVEN | ||||||||
State: | MI | ||||||||
PostalCode: | 490907758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2696371115 | ||||||||
FaxNumber: | 2696391314 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 12/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301048560 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 080H06004 | 01 | MI | BCBSM | OTHER | 080027374 | 01 | MI | RR MEDICARE | OTHER | 1656193 | 05 | MI |   | MEDICAID | 0131169 | 01 | MI | PHP/IBA | OTHER | P53524 | 01 | MI | BCN | OTHER | 5468088 | 01 | MI | AETNA | OTHER |