Provider Demographics
NPI:1235180951
Name:LYONS & POPPLE MEDICAL CORP
Entity Type:Organization
Organization Name:LYONS & POPPLE MEDICAL CORP
Other - Org Name:UP VALLEY ANESTHESIA MEDICAL CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GROUP PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-963-3611
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:650 SANITARIUM
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:CA
Practice Address - Zip Code:94576
Practice Address - Country:US
Practice Address - Phone:707-963-3611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03794ZOtherBS OF CA
CAGR0092420Medicaid
CAZZZ22642ZMedicare PIN