Healthcare Provider Details

I. General information

NPI: 1598143505
Provider Name (Legal Business Name): BENJAMIN LISLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S NATIONAL AVE # 900
SPRINGFIELD MO
65807-5210
US

IV. Provider business mailing address

PO BOX 9007
SPRINGFIELD MO
65808-9007
US

V. Phone/Fax

Practice location:
  • Phone: 417-875-3000
  • Fax:
Mailing address:
  • Phone: 417-875-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2020014928
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: