Provider Demographics
NPI:1215179700
Name:LIVELY, CYNDY EDWARDS (MD)
Entity Type:Individual
Prefix:DR
First Name:CYNDY
Middle Name:EDWARDS
Last Name:LIVELY
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 1:1417 BROOKSTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-1126
Mailing Address - Country:US
Mailing Address - Phone:336-725-7220
Mailing Address - Fax:
Practice Address - Street 1:1417 BROOKSTOWN AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-1126
Practice Address - Country:US
Practice Address - Phone:336-725-7220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26843208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901759Medicaid
NCF45584Medicare UPIN