Basic Information
| Provider Information | |||||||||
| NPI: | 1295727253 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYTHGOE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1661 E CAMELBACK RD STE 205 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850163913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024229000 | ||||||||
| FaxNumber: | 6025565951 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 E THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850123204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023512229 | ||||||||
| FaxNumber: | 6023511500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 21855 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 860966838 | 01 | AZ | TAX ID | OTHER | AZ0860720 | 01 | AZ | BLUE CROSS BLUE SHIELD | OTHER | 198433 | 05 | AZ | MEDICAID | 3372334 | 01 | AZ | CIGNA | OTHER | 1Z1309 | 01 | AZ | HEALTH NET | OTHER |