Provider Demographics
NPI:1568526630
Name:LISELLA, RICHARD S (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:S
Last Name:LISELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 ARDENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-3604
Mailing Address - Country:US
Mailing Address - Phone:615-327-1500
Mailing Address - Fax:615-327-1421
Practice Address - Street 1:337 22ND AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1840
Practice Address - Country:US
Practice Address - Phone:615-327-1500
Practice Address - Fax:615-327-1421
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000009125174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3157326Medicare ID - Type Unspecified
TNA97366Medicare UPIN