Healthcare Provider Details

I. General information

NPI: 1790715654
Provider Name (Legal Business Name): MARY E LYSTER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 DIAMOND HILL RD STE 18
WOONSOCKET RI
02895-1554
US

IV. Provider business mailing address

PO BOX 746088
ATLANTA GA
30374-6088
US

V. Phone/Fax

Practice location:
  • Phone: 401-470-7116
  • Fax: 401-386-2462
Mailing address:
  • Phone: 312-733-9730
  • Fax: 773-866-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD07115
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: