Basic Information
| Provider Information | |||||||||
| NPI: | 1073549820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LISTERMAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 RIVERFRONT PLZ | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660442293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858417297 | ||||||||
| FaxNumber: | 7858560375 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 RIVERFRONT PLZ | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660442293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858417297 | ||||||||
| FaxNumber: | 7858560375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 01/04/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 420040 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100117670B | 05 | KS | MEDICAID |