Basic Information
| Provider Information | |||||||||
| NPI: | 1780789297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYONS | ||||||||
| FirstName: | JO | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LYONS | ||||||||
| OtherFirstName: | JO | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 428 WINN CT | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300301726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703840284 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 031786 | GA | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0102X | 031786 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 13BDDRC01 | 01 | GA | MEDICARE ID | OTHER | 000392972D | 05 | GA | MEDICAID |