Provider Demographics
NPI:1902910557
Name:KEVIN J LYTHGOE MD PC
Entity Type:Organization
Organization Name:KEVIN J LYTHGOE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LYTHGOE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-351-2229
Mailing Address - Street 1:530 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3204
Mailing Address - Country:US
Mailing Address - Phone:602-351-2229
Mailing Address - Fax:602-351-1500
Practice Address - Street 1:530 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3204
Practice Address - Country:US
Practice Address - Phone:602-351-2229
Practice Address - Fax:602-351-1500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21855174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3372334OtherCIGNA
AZ1Z1309OtherHEALTH NET
AZ198433Medicaid
AZ4198433OtherHEALTH CHOICE
AZAZ0860720OtherBLUE CROSS BLUE SHIELD
AZPOB13LYTHKE1OtherMERCY CARE PLAN
AZ3372334OtherCIGNA
AZ1Z1309OtherHEALTH NET
ASG02682Medicare UPIN