Provider Demographics
NPI:1649209545
Name:IGNACE, LYLE ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:ANTHONY
Last Name:IGNACE
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 1:930 W HISTORIC MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3533
Mailing Address - Country:US
Mailing Address - Phone:414-383-9526
Mailing Address - Fax:414-389-3881
Practice Address - Street 1:930 W HISTORIC MITCHELL ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3533
Practice Address - Country:US
Practice Address - Phone:414-383-9526
Practice Address - Fax:414-389-3881
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39069-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Z9506Medicaid
WIK400126747OtherMEDICARE PTAN
WI1649209545Medicaid
AZ474362Medicaid
TX8HZ272Medicare ID - Type UnspecifiedHSZ005
TX8HZ432Medicare ID - Type UnspecifiedHSZ006
TX8HC062Medicare ID - Type UnspecifiedHSZ197
TX8HZ038Medicare ID - Type UnspecifiedHSZ003
AZ474362Medicaid
WIK400126747OtherMEDICARE PTAN
TX8HZ354Medicare ID - Type UnspecifiedHSZ001