Healthcare Provider Details

I. General information

NPI: 1700132537
Provider Name (Legal Business Name): LINDA LEWIS LISTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6319 E US HIGHWAY 36 SUITE 4
AVON IN
46123-6209
US

IV. Provider business mailing address

8902 WATERSIDE CIR
INDIANAPOLIS IN
46278-1158
US

V. Phone/Fax

Practice location:
  • Phone: 317-345-6348
  • Fax:
Mailing address:
  • Phone: 317-345-6348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01028295A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01028295A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: