MEDICARE: DR. DOUGLAS WISTER LIGON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	MD6383	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00282547	OTHER	TN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	810676663	OTHER	TN	TAX IDENTIFACTION
2	MD0000006383	OTHER	TN	MEDICAL LICENSE NUMBER
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	4113788	OTHER	TN	BCBS/TENNCARE SELECT

General Provider Information

NPI Number	:	1376579730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS WISTER LIGON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 268
Second Line	:
City	:	ERIN
State	:	TN
Zip	:	37061-0268
Country	:	US
Telephone Number	:	931-289-2929
Fax Number	:	931-289-2930

Provider Business Practice Location Address
First Line	:	4895 EAST MAIN ST
Second Line	:	STE A
City	:	ERIN
State	:	TN
Zip	:	37061
Country	:	US
Telephone Number	:	931-289-2929
Fax Number	:	931-289-2930

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	01/25/2017

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