Basic Information
| Provider Information | |||||||||
| NPI: | 1376536037 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISMAN | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 OHIO BLVD | ||||||||
| Address2: | SUITE 127 | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478032239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122348261 | ||||||||
| FaxNumber: | 8122348262 | ||||||||
| Practice Location | |||||||||
| Address1: | 7430 N SHADELAND AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175969804 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2005 | ||||||||
| LastUpdateDate: | 05/10/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01030377 | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100251430 | 05 | IN | MEDICAID |