Provider Demographics
NPI:1154667863
Name:JOEL D. LILLY, MD PS
Entity Type:Organization
Organization Name:JOEL D. LILLY, MD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD PS
Authorized Official - Phone:206-292-6488
Mailing Address - Street 1:1221 MADISON ST
Mailing Address - Street 2:SUITE 1210
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3588
Mailing Address - Country:US
Mailing Address - Phone:206-292-6488
Mailing Address - Fax:206-623-2436
Practice Address - Street 1:1221 MADISON ST
Practice Address - Street 2:SUITE 1210
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3588
Practice Address - Country:US
Practice Address - Phone:206-292-6488
Practice Address - Fax:206-623-2436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000127366174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA=========OtherTAX ID
WAH25228Medicare UPIN
WA=========OtherTAX ID
WA121279Medicare UPIN