MEDICARE: DR. LYLE R MUNN M.D.

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	207RH0003X	Hematology & Oncology Physician	01031582	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000214506	OTHER	IN	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1831198928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYLE R MUNN M.D.

Provider Business Mailing Address
First Line	:	1190 N STATE ROAD 49
Second Line	:
City	:	PORTER
State	:	IN
Zip	:	46304-1368
Country	:	US
Telephone Number	:	219-926-2146
Fax Number	:	219-926-3721

Provider Business Practice Location Address
First Line	:	1190 N STATE ROAD 49
Second Line	:
City	:	PORTER
State	:	IN
Zip	:	46304-1368
Country	:	US
Telephone Number	:	219-926-2146
Fax Number	:	219-926-3721

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

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	07/08/2007

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