Provider Demographics
NPI:1639172679
Name:BACK, LYLE MARNIN (MD)
Entity Type:Individual
Prefix:DR
First Name:LYLE
Middle Name:MARNIN
Last Name:BACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 ROUTE 70 E
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-2118
Mailing Address - Country:US
Mailing Address - Phone:856-751-7550
Mailing Address - Fax:856-751-7544
Practice Address - Street 1:1942 ROUTE 70 E
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2118
Practice Address - Country:US
Practice Address - Phone:856-751-7550
Practice Address - Fax:856-751-7544
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
NJMA046399208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE83872Medicare UPIN