Provider Demographics
NPI:1801027131
Name:ROBERT E LYON INTERNAL MEDICINE, INC
Entity Type:Organization
Organization Name:ROBERT E LYON INTERNAL MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:LYON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-281-3432
Mailing Address - Street 1:420 GUNBY AVE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-4406
Mailing Address - Country:US
Mailing Address - Phone:318-281-3432
Mailing Address - Fax:318-281-8850
Practice Address - Street 1:420 GUNBY AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4406
Practice Address - Country:US
Practice Address - Phone:318-281-3432
Practice Address - Fax:318-281-8850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015059207Q00000X
LA014103207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1302112Medicaid
LAB64871Medicare UPIN
LA53809Medicare PIN