Provider Demographics
NPI:1609306760
Name:LISS, MADISON LEIGH
Entity type:Individual
Prefix:MISS
First Name:MADISON
Middle Name:LEIGH
Last Name:LISS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1410
Mailing Address - Country:US
Mailing Address - Phone:610-585-5643
Mailing Address - Fax:
Practice Address - Street 1:2601 E EVESHAM RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9509
Practice Address - Country:US
Practice Address - Phone:856-596-1113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program