Provider Demographics
NPI:1336135821
Name:J RICHARD LILLY MD ABFP CHTD
Entity Type:Organization
Organization Name:J RICHARD LILLY MD ABFP CHTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-779-1014
Mailing Address - Street 1:5804 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20781-1623
Mailing Address - Country:US
Mailing Address - Phone:301-927-7800
Mailing Address - Fax:301-927-0375
Practice Address - Street 1:5804 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20781-1623
Practice Address - Country:US
Practice Address - Phone:301-927-7800
Practice Address - Fax:301-927-0375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD015481400Medicaid
MD707LMedicare PIN
D09277Medicare UPIN
MDC89284Medicare UPIN
MD015481400Medicaid