Provider Demographics
NPI:1730152653
Name:BLACK, LISA B (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:B
Last Name:BLACK
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 1:701 E MARSHALL ST
Mailing Address - Street 2:STE 640
Mailing Address - City:WEST CHESTR
Mailing Address - State:PA
Mailing Address - Zip Code:19380-4412
Mailing Address - Country:US
Mailing Address - Phone:610-738-2709
Mailing Address - Fax:
Practice Address - Street 1:701 E MARSHALL ST STE 640
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4412
Practice Address - Country:US
Practice Address - Phone:610-738-2709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059690L207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232359401OtherMAIN LINE HEALTHCARE
PA001653594Medicaid
PA001653594Medicaid
PA004909N2PMedicare PIN