Provider Demographics
NPI:1215034327
Name:LILEY, MARK DAVID (MSPT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:LILEY
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1665 HAMILTON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1809
Mailing Address - Country:US
Mailing Address - Phone:517-349-1110
Mailing Address - Fax:517-349-6892
Practice Address - Street 1:1665 HAMILTON RD STE 100
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1809
Practice Address - Country:US
Practice Address - Phone:517-349-1110
Practice Address - Fax:517-349-6892
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012918225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30658OtherBCBS
MI236520Medicare ID - Type Unspecified