Provider Demographics
NPI:1124191838
Name:LILLICH, RANDALL KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:KENNETH
Last Name:LILLICH
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 1:5 BOURG CT
Mailing Address - Street 2:
Mailing Address - City:HARAHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70123-4422
Mailing Address - Country:US
Mailing Address - Phone:504-738-5851
Mailing Address - Fax:
Practice Address - Street 1:8166 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-3404
Practice Address - Country:US
Practice Address - Phone:800-456-9121
Practice Address - Fax:214-712-2487
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014665207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAE37135Medicare UPIN