MEDICARE: MS. MARY C LYONS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	085-000952	IL

General Provider Information

NPI Number	:	1801952775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY C LYONS PA

Provider Business Mailing Address
First Line	:	109 CALIFORNIA STREET
Second Line	:	PO BOX 577
City	:	CARTERVILLE
State	:	IL
Zip	:	62918-0577
Country	:	US
Telephone Number	:	618-985-8221
Fax Number	:	618-985-4635

Provider Business Practice Location Address
First Line	:	400 S LEWIS LN
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62901-3547
Country	:	US
Telephone Number	:	618-519-9901
Fax Number	:	519-529-1384

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	09/18/2015

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