Provider Demographics
NPI:1336135631
Name:LILLY, RICHARD B (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:B
Last Name:LILLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:99 E RIVER DR
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3288
Mailing Address - Country:US
Mailing Address - Phone:860-282-4022
Mailing Address - Fax:860-289-0746
Practice Address - Street 1:99 E RIVER DR
Practice Address - Street 2:5TH FLOOR
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3288
Practice Address - Country:US
Practice Address - Phone:860-282-4022
Practice Address - Fax:860-289-0746
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT015713207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001157130Medicaid
CT050000410Medicare ID - Type Unspecified
CT001157130Medicaid