Basic Information
Provider Information | |||||||||
NPI: | 1003856667 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LYMAN | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
Address2: |   | ||||||||
City: | KETTERING | ||||||||
State: | OH | ||||||||
PostalCode: | 454295164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8008750136 | ||||||||
FaxNumber: | 9376194381 | ||||||||
Practice Location | |||||||||
Address1: | 1 MEDICAL CENTER DR | ||||||||
Address2: |   | ||||||||
City: | FRANKLIN | ||||||||
State: | OH | ||||||||
PostalCode: | 450052584 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5133123656 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 10/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35046423 | OH | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000000326508 | 01 | OH | BCBS FOR UVMC | OTHER | 000000316956 | 01 | OH | BCBS | OTHER | 0536003 | 05 | OH |   | MEDICAID | 104734195 | 01 |   | MICHIGAN MEDICAID | OTHER | 104808593 | 05 | MI |   | MEDICAID | 000000559819 | 01 | OH | ANTHEM | OTHER | 000000360666 | 01 | OH | BCBS | OTHER | 000000377131 | 01 | OH | ANTHEM | OTHER | 000000493504 | 01 | OH | ANTHEM/BCBS | OTHER |