Provider Demographics
NPI:1164522785
Name:ATHENS, LYNN BEATTY (MD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:BEATTY
Last Name:ATHENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:A
Other - Last Name:BEATTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:500 KIRTS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4135
Mailing Address - Country:US
Mailing Address - Phone:488-434-6169
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:1500 NE 15TH AVE APT 431
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-4418
Practice Address - Country:US
Practice Address - Phone:810-230-9500
Practice Address - Fax:810-230-0169
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061662207Q00000X
WAMD61187277207Q00000X
ORMD197669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG38163Medicare UPIN