Individual
DR. JACK S LISSAUER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3700 PARK EAST DR, SUITE 100, BEACHWOOD, OH 44122-4339
(216) 593-7700
(216) 593-7190
Mailing address
3700 PARK EAST DR, SUITE 100, BEACHWOOD, OH 44122-4339
(216) 593-7700
(216) 593-7190
Taxonomy
Speciality
Code
Description
License number
State
207RG0100X
Gastroenterology Physician
Primary
35038212L
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000127021
ANTHEM BCBS & ANTHEM SR
OH
05
—
0307699
—
OH
01
—
4079026
AETNA
OH
01
—
5089882001
CIGNA
OH
01
—
603650
UNITED HEALTHCARE
OH
01
—
P1482889
OXFORD INSURANCE
OH
01
—
R38212
APEX & SUMMACARE
OH
Enumeration date
07/15/2005
Last updated
10/24/2007
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