Provider Demographics
NPI:1831300748
Name:LYON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LYON
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 1:2850 W 95TH ST
Mailing Address - Street 2:STE 302
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2741
Mailing Address - Country:US
Mailing Address - Phone:708-581-7308
Mailing Address - Fax:708-274-4027
Practice Address - Street 1:2850 W 95TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2735
Practice Address - Country:US
Practice Address - Phone:708-422-2242
Practice Address - Fax:708-422-2270
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036116228208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
02232706OtherBCBS
P00467991OtherMEDICARE RAILROAD PTAN
211475OtherMEDICAN PTAN
IL036116228Medicaid
DG0826OtherMEDICARE RAILROAD GROUP NUMBER
211475OtherMEDICAN PTAN
02232706OtherBCBS
ILIL3596052Medicare PIN
IL964290015Medicare PIN