Basic Information
| Provider Information | |||||||||
| NPI: | 1720043946 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISELLA | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1367 WASHINGTON AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122061069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184892666 | ||||||||
| FaxNumber: | 5184895933 | ||||||||
| Practice Location | |||||||||
| Address1: | 1367 WASHINGTON AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122061069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184892666 | ||||||||
| FaxNumber: | 5184895933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 02/28/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0004X | 4301087211 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02865736 | 05 | NY | MEDICAID |