Basic Information
| Provider Information | |||||||||
| NPI: | 1972590438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYONS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | SHERRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LYONS | ||||||||
| OtherFirstName: | JACK | ||||||||
| OtherMiddleName: | SHERRY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10335 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622409870 | ||||||||
| FaxNumber: | 2622409869 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 WILLOW AVE | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | HOBOKEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014181820 | ||||||||
| FaxNumber: | 2014181822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 11/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 25MA03972600 | NJ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2109808 | 05 | NJ | MEDICAID |