Provider Demographics
NPI:1346453644
Name:LILLEGARD, JOSEPH B (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:B
Last Name:LILLEGARD
Suffix:
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 1:2530 CHICAGO AVE
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4289
Mailing Address - Country:US
Mailing Address - Phone:612-813-8606
Mailing Address - Fax:612-813-8005
Practice Address - Street 1:2530 CHICAGO AVE
Practice Address - Street 2:SUITE 550
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4289
Practice Address - Country:US
Practice Address - Phone:612-813-8606
Practice Address - Fax:612-813-8005
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN50054208600000X
PAMD4513842086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN016990000Medicaid
WI35217100Medicaid
IAENROLLEDMedicaid
WI35217100Medicaid
MN020002847Medicare PIN