1831300748 NPI number — MARK LYON MD

Table of content: MARK LYON MD (NPI 1831300748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831300748 NPI number — MARK LYON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYON
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831300748
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2850 W 95TH ST
Provider Second Line Business Mailing Address:
STE 302
Provider Business Mailing Address City Name:
EVERGREEN PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60805-2741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-581-7308
Provider Business Mailing Address Fax Number:
708-274-4027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2850 W 95TH ST
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
EVERGREEN PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60805-2735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-422-2242
Provider Business Practice Location Address Fax Number:
708-422-2270
Provider Enumeration Date:
05/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  036116228 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02232706 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00467991 . This is a "MEDICARE RAILROAD PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 211475 . This is a "MEDICAN PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 036116228 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: DG0826 . This is a "MEDICARE RAILROAD GROUP NUMBER" identifier . This identifiers is of the category "OTHER".




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