Healthcare Provider Details

I. General information

NPI: 1255862926
Provider Name (Legal Business Name): ANDREW LYELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3204 PARKWOOD AVE
RICHMOND VA
23221-3421
US

IV. Provider business mailing address

180 S 3RD ST STE 300
BELLEVILLE IL
62220-1952
US

V. Phone/Fax

Practice location:
  • Phone: 703-955-6703
  • Fax:
Mailing address:
  • Phone: 618-233-5480
  • Fax: 618-222-4790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101266386
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101266386
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125070799
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: