Healthcare Provider Details

I. General information

NPI: 1265693857
Provider Name (Legal Business Name): DR MICHAEL LYONS PROFFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1558 MONTEITH AVE
HERNANDO MS
38632-7685
US

IV. Provider business mailing address

1558 MONTEITH AVE
HERNANDO MS
38632-7685
US

V. Phone/Fax

Practice location:
  • Phone: 662-449-3663
  • Fax: 662-449-3676
Mailing address:
  • Phone: 662-449-3663
  • Fax: 662-449-3676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number80187
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number80187
License Number StateMS

VIII. Authorized Official

Name: DR. MICHAEL LYONS
Title or Position: OWNER
Credential: PROFESSIONAL
Phone: 901-493-5530