Provider Demographics
NPI:1285677955
Name:LILLY, ALBERT JACKSON III (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:JACKSON
Last Name:LILLY
Suffix:III
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:PO BOX 5579
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-5579
Mailing Address - Country:US
Mailing Address - Phone:541-706-3700
Mailing Address - Fax:541-706-3730
Practice Address - Street 1:61250 SE COOMBS PL
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3704
Practice Address - Country:US
Practice Address - Phone:541-706-5930
Practice Address - Fax:541-706-5931
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22604207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ958936Medicaid
H32853Medicare UPIN
8EB955Medicare ID - Type Unspecified