Basic Information
| Provider Information | |||||||||
| NPI: | 1932201423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYONS | ||||||||
| FirstName: | ALFRED | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LYONS | ||||||||
| OtherFirstName: | A. | ||||||||
| OtherMiddleName: | GORDON | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004880 | ||||||||
| FaxNumber: | 6012005929 | ||||||||
| Practice Location | |||||||||
| Address1: | 970 LAKELAND DR | ||||||||
| Address2: | 45 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004690 | ||||||||
| FaxNumber: | 6012004698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2006 | ||||||||
| LastUpdateDate: | 10/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 10603 | MS | N | Other Service Providers | Specialist | 208VP0014X | 10603 | MS | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01237614 | 01 | MS | RAILROAD MEDICARE | OTHER | 00115787 | 05 | MS | MEDICAID |