Healthcare Provider Details

I. General information

NPI: 1649652728
Provider Name (Legal Business Name): BRIDGET LYNN KISTNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 S 6TH ST
SPRINGFIELD IL
62703-2499
US

IV. Provider business mailing address

PO BOX 19248
SPRINGFIELD IL
62794-9248
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-7541
  • Fax:
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number036162130
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036162130
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2020011852
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: