Healthcare Provider Details

I. General information

NPI: 1255905923
Provider Name (Legal Business Name): EMILY LU LISTER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 4TH ST
SPRINGFIELD IL
62702-5238
US

IV. Provider business mailing address

PO BOX 19670
SPRINGFIELD IL
62794-9670
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-757-8161
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-757-8161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.077791
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01090180A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125077791
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: