Healthcare Provider Details

I. General information

NPI: 1215159744
Provider Name (Legal Business Name): AJA LYSTILA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2512 HURST DR. FAMILY MEDICINE
MATTOON IL
61938-9388
US

IV. Provider business mailing address

611 W. PARK ST. BWPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-5900
  • Fax: 217-258-5904
Mailing address:
  • Phone: 217-383-6792
  • Fax: 217-258-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036119163
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036119163
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: