Healthcare Provider Details

I. General information

NPI: 1174909592
Provider Name (Legal Business Name): IAN LYTLE MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18181 OAKWOOD BLVD SUITE 200
DEARBORN MI
48124-5032
US

IV. Provider business mailing address

18181 OAKWOOD BLVD SUITE 200
DEARBORN MI
48124-5032
US

V. Phone/Fax

Practice location:
  • Phone: 313-399-9775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301088089
License Number StateMI

VIII. Authorized Official

Name: DR. IAN FRAZIER LYTLE
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 313-399-9775