Provider Demographics
NPI:1073962577
Name:LILES, MICHAEL EDWARD
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:LILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 HOGBIN RD
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-5228
Mailing Address - Country:US
Mailing Address - Phone:856-265-8772
Mailing Address - Fax:856-506-8647
Practice Address - Street 1:528 HOGBIN RD
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-5228
Practice Address - Country:US
Practice Address - Phone:856-265-8772
Practice Address - Fax:856-506-8647
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ634660247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist