Provider Demographics
NPI:1295374270
Name:LILLY AESTHETICS SC
Entity Type:Organization
Organization Name:LILLY AESTHETICS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MERCY
Authorized Official - Middle Name:
Authorized Official - Last Name:ODUEYUNGBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-317-7338
Mailing Address - Street 1:PO BOX 644
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-0644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 S HIGHLAND AVE STE 220
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-7103
Practice Address - Country:US
Practice Address - Phone:630-317-7338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty