Provider Demographics
NPI:1205825957
Name:GREEN, LYRIC L (MD)
Entity Type:Individual
Prefix:
First Name:LYRIC
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:46591 ROMEO PLANK RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5742
Mailing Address - Country:US
Mailing Address - Phone:586-226-6250
Mailing Address - Fax:586-226-6255
Practice Address - Street 1:46591 ROMEO PLANK RD
Practice Address - Street 2:SUITE 205
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5742
Practice Address - Country:US
Practice Address - Phone:586-226-6250
Practice Address - Fax:586-226-6255
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301056540208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3519710Medicaid
OM77390Medicare ID - Type Unspecified
MI0M92510Medicare PIN
MI3519710Medicaid
MIM92510002Medicare PIN