Provider Demographics
NPI:1043381288
Name:IRA ZACHARY DYME MD
Entity Type:Organization
Organization Name:IRA ZACHARY DYME MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:ZACHARY
Authorized Official - Last Name:DYME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-482-1111
Mailing Address - Street 1:2909 E GRAND RIV
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-4300
Mailing Address - Country:US
Mailing Address - Phone:517-482-1111
Mailing Address - Fax:517-482-1119
Practice Address - Street 1:2909 E GRAND RIV
Practice Address - Street 2:SUITE 108
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4300
Practice Address - Country:US
Practice Address - Phone:517-482-1111
Practice Address - Fax:517-482-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010467432084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101559420Medicaid
MI3503311161OtherBCBS OF MICHIGAN
MI3503311161OtherBCBS OF MICHIGAN