Healthcare Provider Details

I. General information

NPI: 1730260159
Provider Name (Legal Business Name): WILLIAM FRANKLIN LYTLE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 STUART ST MACH ATTN: MCXL-PQ (CREDENTIALS)
COLUMBIA SC
29207-5700
US

IV. Provider business mailing address

4500 STUART ST MACH ATTN: MCXL-PQ (CREDENTIALS)
COLUMBIA SC
29207-5700
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-2618
  • Fax: 803-751-2689
Mailing address:
  • Phone: 803-751-2618
  • Fax: 803-751-2689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME12368
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: