Basic Information
Provider Information | |||||||||
NPI: | 1164522785 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ATHENS | ||||||||
FirstName: | LYNN | ||||||||
MiddleName: | BEATTY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BEATTY | ||||||||
OtherFirstName: | LYNN | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 500 KIRTS BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | TROY | ||||||||
State: | MI | ||||||||
PostalCode: | 480844135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4884346169 | ||||||||
FaxNumber: | 8556186655 | ||||||||
Practice Location | |||||||||
Address1: | 1500 NE 15TH AVE APT 431 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972324418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8102309500 | ||||||||
FaxNumber: | 8102300169 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2006 | ||||||||
LastUpdateDate: | 08/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301061662 | MI | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD61187277 | WA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD197669 | OR | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.