Basic Information
| Provider Information | |||||||||
| NPI: | 1215159744 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYSTILA | ||||||||
| FirstName: | AJA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 2172585904 | ||||||||
| Practice Location | |||||||||
| Address1: | 2512 HURST DR. | ||||||||
| Address2: | FAMILY MEDICINE | ||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619389388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172585900 | ||||||||
| FaxNumber: | 2172585904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 03/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036119163 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 036119163 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036119163 | 05 | IL | MEDICAID |