=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225265598
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT E LYON INTERNAL MEDICINE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2009
-----------------------------------------------------
Last Update Date | 06/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 GUNBY AVE
-----------------------------------------------------
City | BASTROP
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71220-4406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-281-3432
-----------------------------------------------------
Fax | 318-281-8850
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 GUNBY AVE
-----------------------------------------------------
City | BASTROP
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71220-4406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-281-3432
-----------------------------------------------------
Fax | 318-281-8850
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT E LYON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 318-281-3432
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 015059
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 014103
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------