Provider Demographics
NPI:1417060864
Name:KENNETH R LISTER, MD, PC
Entity Type:Organization
Organization Name:KENNETH R LISTER, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ELEAZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-694-6919
Mailing Address - Street 1:PO BOX 52364
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-2364
Mailing Address - Country:US
Mailing Address - Phone:865-694-6919
Mailing Address - Fax:865-694-4339
Practice Address - Street 1:116 BROWN AVE
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-7703
Practice Address - Country:US
Practice Address - Phone:865-694-6919
Practice Address - Fax:865-694-4339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3722060Medicare ID - Type Unspecified