Basic Information
| Provider Information | |||||||||
| NPI: | 1790720290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYTLE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CAROL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508180 | ||||||||
| FaxNumber: | 9123507221 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508180 | ||||||||
| FaxNumber: | 9123507221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 056132 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 2080P0203X | 056132 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 511379152A | 05 | GA | MEDICAID | 10065021 | 01 | GA | AMERIGROUP | OTHER | 52172893-002 | 01 | GA | BCBS GA | OTHER | G56132 | 05 | SC | MEDICAID | 349798 | 01 | GA | WELLCARE | OTHER |