Provider Demographics
NPI:1922396126
Name:LYLE, RUSSELL RAY (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:RAY
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 1:303 HUNTER CREST
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157
Mailing Address - Country:US
Mailing Address - Phone:601-605-9995
Mailing Address - Fax:
Practice Address - Street 1:303 HUNTER CREST
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157
Practice Address - Country:US
Practice Address - Phone:601-605-9995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0017208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics