Healthcare Provider Details

I. General information

NPI: 1912989898
Provider Name (Legal Business Name): LYSLE KENNEDY AILSTOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 W ARLINGTON BLVD STE 210
GREENVILLE NC
27834-5758
US

IV. Provider business mailing address

PO BOX 30750
GREENVILLE NC
27833-0750
US

V. Phone/Fax

Practice location:
  • Phone: 252-752-5000
  • Fax: 252-931-7694
Mailing address:
  • Phone: 252-752-5000
  • Fax: 252-931-7694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number9600437
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: