Provider Demographics
NPI:1245295179
Name:CAMPISANO, LISA C (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:CAMPISANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:7926 PRESTON HWY
Practice Address - Street 2:SUITE 106
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-964-4357
Practice Address - Fax:502-966-5948
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27273207R00000X, 208D00000X
IN01045735A207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200489100Medicaid
INP00305257OtherRAILROAD MEDICARE
KYP00838074OtherRAILROAD MEDICARE - NICC
00000038150OtherANTHEM
129355POtherSIHO
INP00305257OtherRAILROAD MEDICARE
129355POtherSIHO
KYF4995Medicare UPIN
KYP00838074OtherRAILROAD MEDICARE - NICC