MEDICARE: KENNETH R LISTER MD

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	MD8024	TN

General Provider Information

NPI Number	:	1730187980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH R LISTER MD

Provider Business Mailing Address
First Line	:	49 CLEVELAND ST STE 230
Second Line	:
City	:	CROSSVILLE
State	:	TN
Zip	:	38555-2854
Country	:	US
Telephone Number	:	931-210-5701
Fax Number	:	931-210-5702

Provider Business Practice Location Address
First Line	:	49 CLEVELAND ST STE 230
Second Line	:
City	:	CROSSVILLE
State	:	TN
Zip	:	38555-2854
Country	:	US
Telephone Number	:	931-210-5701
Fax Number	:	931-210-5702

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

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	09/06/2023

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Directions to “ KENNETH R LISTER MD” Practice Location

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