Provider Demographics
NPI:1225182454
Name:LILLEBOE, POLLY A (MD)
Entity Type:Individual
Prefix:DR
First Name:POLLY
Middle Name:A
Last Name:LILLEBOE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-1952
Mailing Address - Country:US
Mailing Address - Phone:517-663-9555
Mailing Address - Fax:517-663-3430
Practice Address - Street 1:805 OAKLAND STREET
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879
Practice Address - Country:US
Practice Address - Phone:989-227-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047563174400000X
MI430104756207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382168683OtherTAX ID
MI1728309Medicaid
MI382168683OtherTAX ID
C37612004Medicare PIN