Healthcare Provider Details

I. General information

NPI: 1265481204
Provider Name (Legal Business Name): WILLIAM LISTON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CAMPUS DR
HANCOCK MI
49930-1569
US

IV. Provider business mailing address

500 CAMPUS DR
HANCOCK MI
49930-1569
US

V. Phone/Fax

Practice location:
  • Phone: 906-483-1040
  • Fax: 906-483-1043
Mailing address:
  • Phone: 906-483-1040
  • Fax: 906-483-1043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMI51012076
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: