Provider Demographics
NPI:1124034822
Name:BURRELL, LYDIA L (MD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:L
Last Name:BURRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 S GREEN RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-4128
Mailing Address - Country:US
Mailing Address - Phone:216-297-3070
Mailing Address - Fax:216-297-3156
Practice Address - Street 1:1611 S GREEN RD
Practice Address - Street 2:SUITE 160
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-4128
Practice Address - Country:US
Practice Address - Phone:216-297-3070
Practice Address - Fax:216-297-3156
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35068380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0142214Medicaid
OH0142214Medicaid
OHG03295Medicare UPIN