Basic Information
| Provider Information | |||||||||
| NPI: | 1508822107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINDLIN | ||||||||
| FirstName: | LYLE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1540 LAKE LANSING RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489123756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179133800 | ||||||||
| FaxNumber: | 5179133901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 LAKE LANSING RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489123756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179133800 | ||||||||
| FaxNumber: | 5179133901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 07/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5101007752 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4739235 | 05 | MI | MEDICAID |