Provider Demographics
NPI:1154769545
Name:MYC, LUKASZ (MD)
Entity type:Individual
Prefix:
First Name:LUKASZ
Middle Name:
Last Name:MYC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7987
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36670-0987
Mailing Address - Country:US
Mailing Address - Phone:251-633-0573
Mailing Address - Fax:251-633-7367
Practice Address - Street 1:5955 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3135
Practice Address - Country:US
Practice Address - Phone:251-633-0573
Practice Address - Fax:251-633-7367
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101260427207R00000X, 208M00000X
AL40964207R00000X, 207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALZZ2155OtherVIVA HEALTH
AL251324Medicaid
AL251328Medicaid
AL253074Medicaid
AL251338Medicaid
AL4150261OtherAETNA
AL512-44737OtherBCBS
ALP02511079OtherRR MEDICARE
AL512-44735OtherBCBS
AL6099394OtherUHC
ALA10255AOtherMEDICARE
AL512-44736OtherBCBS
MS02739713Medicaid
AL512-44734OtherBCBS