Provider Demographics
NPI:1356632152
Name:LISIC, ERIC (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:LISIC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-1726
Mailing Address - Country:US
Mailing Address - Phone:931-783-5582
Mailing Address - Fax:931-526-6760
Practice Address - Street 1:128 N WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2493
Practice Address - Country:US
Practice Address - Phone:931-783-5848
Practice Address - Fax:931-528-1266
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6018834OtherBCBS
KY7100423360Medicaid
TNQ007183Medicaid
TN6018834OtherBCBS