Healthcare Provider Details

I. General information

NPI: 1255322897
Provider Name (Legal Business Name): JOHN TIMOTHY LYSACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST GRB 2
BOSTON MA
02114-2621
US

IV. Provider business mailing address

PO BOX 9142
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-8320
  • Fax: 617-726-3077
Mailing address:
  • Phone: 617-724-0287
  • Fax: 617-726-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number224049
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: