Provider Demographics
NPI:1699753897
Name:MIKOLICH, LYNN M (MD)
Entity type:Individual
Prefix:DR
First Name:LYNN
Middle Name:M
Last Name:MIKOLICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1006
Mailing Address - Country:US
Mailing Address - Phone:330-480-3097
Mailing Address - Fax:330-480-3416
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:330-480-3097
Practice Address - Fax:330-480-3416
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-7601208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000115422OtherANTHEM
OH0435961Medicaid
OH000000115422OtherANTHEM
OHA79793Medicare UPIN