Basic Information
| Provider Information | |||||||||
| NPI: | 1619916012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LISLE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 ARLEY WAY | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299104883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437068690 | ||||||||
| FaxNumber: | 8437065066 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 ARLEY WAY | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299104883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437068690 | ||||||||
| FaxNumber: | 8437065066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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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 | D14318 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 32158 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | S1420009 | 01 | MD | CAREFIRST REGIONAL GBMC | OTHER | KJ24GB-41705201 | 01 | MD | CAREFIRST OF MD GBMC | OTHER | 026441500 | 05 | MD | MEDICAID |