Individual
MARY FENNELL LYLES
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
MEDICAL CENTER BLVD, WINSTON SALEM, NC 27157-0001
(336) 716-2255
Mailing address
PO BOX 344, WINSTON SALEM, NC 27102-0344
(336) 716-2255
Taxonomy
Speciality
Code
Description
License number
State
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
Primary
22777
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10656
PARTNERS
NC
01
—
27314
MEDCOST
NC
05
—
3810011190
—
WV
01
—
53464
BCBS
NC
01
—
7449759
AETNA
—
05
—
7602715
—
VA
05
—
8953464
—
NC
05
—
Q22777
—
SC
Enumeration date
12/13/2005
Last updated
05/14/2008
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