Individual
LISA MICHELE MCTAVISH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1500 SALEM ST, LAFAYETTE, IN 47904-2164
(765) 448-8000
(765) 379-3312
Mailing address
1200 W WHITE RIVER BLVD, MUNCIE, IN 47303-4988
(877) 668-5621
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
01044255A
IN
207P00000X
Emergency Medicine Physician
01044255A
IN
207Q00000X
Family Medicine Physician
Primary
01044255A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000197894
ANTHEM PROVIDER NUMBER - FAMILY MEDICINE
IN
01
—
000000877221
ANTHEM PROVIDER NUMBER - URGENT CARE
IN
01
—
000000990880
ANTHEM PROVIDER NUMBER - DERMATOLOGY
IN
01
—
10825581
CAQH NUMBER
IN
05
—
200083620
—
IN
01
—
9007117
PHCS PID NUMBER
IN
Enumeration date
03/15/2006
Last updated
07/22/2024
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