Provider Demographics
NPI:1205039559
Name:KENNETH M. LYSSY JR MD PA
Entity Type:Organization
Organization Name:KENNETH M. LYSSY JR MD PA
Other - Org Name:DR KENNETH M LYSSY JR MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUHRADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-256-9500
Mailing Address - Street 1:6100 BANDERA
Mailing Address - Street 2:# 403
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-1653
Mailing Address - Country:US
Mailing Address - Phone:210-256-9500
Mailing Address - Fax:210-256-8720
Practice Address - Street 1:6100 BANDERA RD
Practice Address - Street 2:SUITE 403
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1652
Practice Address - Country:US
Practice Address - Phone:210-256-9500
Practice Address - Fax:210-256-8720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Z062OtherMEDICARE INDIVIDUAL PTAN
TX00Z062OtherMEDICARE GROUP PTAN
TX00Z062OtherMEDICARE GROUP PTAN