Healthcare Provider Details

I. General information

NPI: 1013920651
Provider Name (Legal Business Name): ALAN P LYSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 N BALLAS RD
SAINT LOUIS MO
63131-2329
US

IV. Provider business mailing address

3015 N BALLAS RD
SAINT LOUIS MO
63131-2329
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5514
  • Fax: 314-996-5390
Mailing address:
  • Phone: 314-996-5514
  • Fax: 314-996-5390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberR2C26
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: