Healthcare Provider Details

I. General information

NPI: 1902899891
Provider Name (Legal Business Name): JUDY S LYZAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S MAIN ST ST ANTHONY MEDICAL CENTER
CROWN POINT IN
46307-8481
US

IV. Provider business mailing address

113 E 4TH ST
MICHIGAN CITY IN
46360-3301
US

V. Phone/Fax

Practice location:
  • Phone: 219-757-6322
  • Fax: 219-757-5891
Mailing address:
  • Phone: 219-873-3130
  • Fax: 219-873-3132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01045230A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036087853
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: