Provider Demographics
NPI:1790720290
Name:LYTLE, MARY CAROL (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAROL
Last Name:LYTLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4700 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-8180
Mailing Address - Fax:912-350-7221
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-8180
Practice Address - Fax:912-350-7221
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056132207L00000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511379152AMedicaid
GA10065021OtherAMERIGROUP
GA52172893-002OtherBCBS GA
SCG56132Medicaid
GA349798OtherWELLCARE
GA81BBBDBMedicare PIN
GA511379152AMedicaid