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General NPI Number Information
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NPI Number | 1417060864
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Entity Type | Organization
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Legal Business Name | KENNETH R LISTER, MD, PC
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Dates
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Enumeration Date | 08/17/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 116 BROWN AVE
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City | CROSSVILLE
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State | TN
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Zip | 38555-7703
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Country | US
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Telephone | 865-694-6919
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Fax | 865-694-4339
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Provider Business Mailing Address
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Address Line | PO BOX 52364
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City | KNOXVILLE
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State | TN
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Zip | 37950-2364
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Country | US
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Telephone | 865-694-6919
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Fax | 865-694-4339
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | HEATHER ELEAZER
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Credential |
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Telephone | 865-694-6919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State | TN
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