Provider Demographics
NPI:1073568796
Name:LISTON, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:LISTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:12251 S 80TH AVE STE 1630
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1256
Mailing Address - Country:US
Mailing Address - Phone:708-923-5173
Mailing Address - Fax:708-923-5018
Practice Address - Street 1:12255 S 80TH AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1270
Practice Address - Country:US
Practice Address - Phone:708-923-4400
Practice Address - Fax:708-923-4421
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036.064198207X00000X
IL036064198174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064198Medicaid
ILC47537Medicare UPIN
IL036064198Medicaid