Healthcare Provider Details

I. General information

NPI: 1164636783
Provider Name (Legal Business Name): MYRON RAE LINDLEY ST. LOUIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 SUN N LAKE BLVD SUITE 103
SEBRING FL
33872-2162
US

IV. Provider business mailing address

4301 SUN N LAKE BLVD SUITE 103
SEBRING FL
33872-2162
US

V. Phone/Fax

Practice location:
  • Phone: 863-385-1900
  • Fax: 863-385-9229
Mailing address:
  • Phone: 863-385-1900
  • Fax: 863-385-9229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME 107124
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD438171
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: