Provider Demographics
NPI:1407844566
Name:LU, MARY LYN T (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:MARY LYN
Middle Name:T
Last Name:LU
Suffix:
Gender:F
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2257
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-2257
Mailing Address - Country:US
Mailing Address - Phone:606-432-0061
Mailing Address - Fax:606-432-0095
Practice Address - Street 1:126 TRIVETTE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1275
Practice Address - Country:US
Practice Address - Phone:606-432-0061
Practice Address - Fax:606-432-0095
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY256422086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64256423Medicaid
KY0114191000OtherWV MEDICAID
KY240005992OtherR/R MEDICARE
KY000000051790OtherBC/BS
KY1532903OtherUMWA
KY64256423Medicaid
KYP400016437Medicare PIN