=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073647178
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLDE TOWN ANESTHESIA ASSOCIATES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 MITCHELLVILLE RD SUITE B322
-----------------------------------------------------
City | BOWIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20716-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-820-6418
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4520 KING ST
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22302-1347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-820-6418
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT LEE LYLES JR.
-----------------------------------------------------
Credential | MD, PHD
-----------------------------------------------------
Telephone | 703-820-6418
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0101035966
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------