Provider Demographics
NPI:1104858612
Name:LILE, BUDDY WAYNE (MD)
Entity Type:Individual
Prefix:MR
First Name:BUDDY
Middle Name:WAYNE
Last Name:LILE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BUD
Other - Middle Name:WAYNE
Other - Last Name:INGRAM-LILE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:550 MAIN STREET
Mailing Address - Street 2:SUITE 230
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112
Mailing Address - Country:US
Mailing Address - Phone:612-326-7558
Mailing Address - Fax:612-454-2087
Practice Address - Street 1:550 MAIN STREET
Practice Address - Street 2:SUITE 230
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112
Practice Address - Country:US
Practice Address - Phone:612-326-7558
Practice Address - Fax:612-454-2087
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00107052084P0800X
MN493292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT042-0010705OtherVERMONT STATE LICENSE
MN1010386Medicaid
VT1010386Medicaid
VTBL4764379OtherDEA REGISTRATION
VTBL4764379OtherDEA REGISTRATION
MNVN3350Medicare UPIN
MN260002670Medicare PIN