Basic Information
| Provider Information | |||||||||
| NPI: | 1831300748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYON | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2850 W 95TH ST | ||||||||
| Address2: | STE 302 | ||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608052741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085817308 | ||||||||
| FaxNumber: | 7082744027 | ||||||||
| Practice Location | |||||||||
| Address1: | 2850 W 95TH ST | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608052735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084222242 | ||||||||
| FaxNumber: | 7084222270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 05/27/2016 | ||||||||
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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 | 208800000X | 036116228 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 036116228 | 05 | IL | MEDICAID | P00467991 | 01 | MEDICARE RAILROAD PTAN | OTHER | 211475 | 01 | MEDICAN PTAN | OTHER | DG0826 | 01 | MEDICARE RAILROAD GROUP NUMBER | OTHER | 02232706 | 01 | BCBS | OTHER |