Provider Demographics
NPI:1700851037
Name:LYLE, WILLIAM GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:GLENN
Last Name:LYLE
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 1:1112 DRESSER CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7303
Mailing Address - Country:US
Mailing Address - Phone:919-872-2616
Mailing Address - Fax:919-872-2771
Practice Address - Street 1:1112 DRESSER CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7303
Practice Address - Country:US
Practice Address - Phone:919-872-2616
Practice Address - Fax:919-872-2771
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912585Medicaid
NC2280296Medicare ID - Type Unspecified
NCF85100Medicare UPIN