Healthcare Provider Details

I. General information

NPI: 1619916012
Provider Name (Legal Business Name): ROBERT W LISLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 ARLEY WAY SUITE 201
BLUFFTON SC
29910-4883
US

IV. Provider business mailing address

11 ARLEY WAY SUITE 201
BLUFFTON SC
29910-4883
US

V. Phone/Fax

Practice location:
  • Phone: 843-706-8690
  • Fax: 843-706-5066
Mailing address:
  • Phone: 843-706-8690
  • Fax: 843-706-5066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD14318
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32158
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: