1932201423 NPI number — ALFRED GORDON LYONS M.D.

Table of content: ALFRED GORDON LYONS M.D. (NPI 1932201423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932201423 NPI number — ALFRED GORDON LYONS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYONS
Provider First Name:
ALFRED
Provider Middle Name:
GORDON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LYONS
Provider Other First Name:
A.
Provider Other Middle Name:
GORDON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1932201423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23666
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39225-3666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-200-4880
Provider Business Mailing Address Fax Number:
601-200-5929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
970 LAKELAND DR
Provider Second Line Business Practice Location Address:
45
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-200-4690
Provider Business Practice Location Address Fax Number:
601-200-4698
Provider Enumeration Date:
09/04/2006

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: 174400000X , with the licence number:  10603 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: 10603 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P01237614 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00115787 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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