Provider Demographics
NPI:1205817699
Name:LILIK, KENNETH WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:LILIK
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 1:3 W OLIVE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2572
Mailing Address - Country:US
Mailing Address - Phone:570-961-9947
Mailing Address - Fax:570-341-5043
Practice Address - Street 1:311 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1230
Practice Address - Country:US
Practice Address - Phone:570-961-3933
Practice Address - Fax:570-342-4318
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026664E2084N0400X, 2084N0402X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001034077001Medicaid
PAE55459Medicare UPIN
PA001034077001Medicaid