Provider Demographics
NPI:1619916012
Name:LISLE, ROBERT W (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:LISLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:11 ARLEY WAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-4883
Mailing Address - Country:US
Mailing Address - Phone:843-706-8690
Mailing Address - Fax:843-706-5066
Practice Address - Street 1:11 ARLEY WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-4883
Practice Address - Country:US
Practice Address - Phone:843-706-8690
Practice Address - Fax:843-706-5066
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD14318207Q00000X
SC32158207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS1420009OtherCAREFIRST REGIONAL GBMC
MDKJ24GB-41705201OtherCAREFIRST OF MD GBMC
MD026441500Medicaid
SCAA49166305Medicare PIN
MDKJ24GB-41705201OtherCAREFIRST OF MD GBMC
B67276Medicare UPIN