Provider Demographics
NPI:1174524821
Name:CORUM, LISA LEIGH (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LEIGH
Last Name:CORUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11501 REDWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2362
Mailing Address - Country:US
Mailing Address - Phone:803-487-4006
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:175 S ENGLISH STATION RD STE 226
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-4199
Practice Address - Country:US
Practice Address - Phone:502-244-0911
Practice Address - Fax:502-253-0581
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33949207Q00000X
NC2013-02331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50024464OtherPASSPORT
KY000000624358OtherANTHEM
KY3722989000OtherPASSPORT ADVANTAGE
SC187522Medicaid
KYK204930-KOHMGOtherMEDICARE
KY64339492Medicaid
KY64339492Medicaid