Provider Demographics
NPI:1871567297
Name:LISCHWE, DANIEL H (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:H
Last Name:LISCHWE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12255 DE PAUL DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12255 DE PAUL DR
Practice Address - Street 2:SUITE 600
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2510
Practice Address - Country:US
Practice Address - Phone:314-291-1074
Practice Address - Fax:314-291-0802
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00055177OtherRAILROAD MEDICARE
MOA09854Medicare UPIN