=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699768978
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY A LISTER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2005
-----------------------------------------------------
Last Update Date | 04/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 312 EAST MAIN MCFARLAND CLINIC, PC
-----------------------------------------------------
City | MARSHALLTOWN
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50158-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-752-0654
-----------------------------------------------------
Fax | 641-844-2206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5541 HIGHWAY 1
-----------------------------------------------------
City | MARKSVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71351-2650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-752-0654
-----------------------------------------------------
Fax | 641-844-2206
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 33486
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------