Healthcare Provider Details

I. General information

NPI: 1639656192
Provider Name (Legal Business Name): BRENT CHARLES LISTER TRULL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 ABRAHAM FLEXNER WAY STE 850
LOUISVILLE KY
40202-1858
US

IV. Provider business mailing address

946 GOSS AVE APT 2205
LOUISVILLE KY
40217-2281
US

V. Phone/Fax

Practice location:
  • Phone: 502-562-0312
  • Fax:
Mailing address:
  • Phone: 502-657-9220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number51182
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: