Provider Demographics
NPI:1730187980
Name:LISTER, KENNETH R (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:LISTER
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 1:49 CLEVELAND ST STE 230
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-2854
Mailing Address - Country:US
Mailing Address - Phone:931-210-5701
Mailing Address - Fax:931-210-5702
Practice Address - Street 1:49 CLEVELAND ST STE 230
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-2854
Practice Address - Country:US
Practice Address - Phone:931-210-5701
Practice Address - Fax:931-210-5702
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD8024207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDF1614OtherRAILROAD MEDICARE
374041600OtherDEPT OF LABOR
TN4008687OtherBLUECROSS BLUESHIELD
TN3722060Medicaid
TN3722060Medicare PIN
TNDF1614OtherRAILROAD MEDICARE
TN4008687OtherBLUECROSS BLUESHIELD