Provider Demographics
NPI:1376507566
Name:LILLY, JOSIAH KENNETH III (MD MS)
Entity Type:Individual
Prefix:
First Name:JOSIAH
Middle Name:KENNETH
Last Name:LILLY
Suffix:III
Gender:M
Credentials:MD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 VIRGINIA AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1603
Mailing Address - Country:US
Mailing Address - Phone:304-925-2922
Mailing Address - Fax:304-926-8009
Practice Address - Street 1:4001 VIRGINIA AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1603
Practice Address - Country:US
Practice Address - Phone:304-925-2922
Practice Address - Fax:304-926-8009
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11322208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0201994Medicaid
WV9339481Medicare ID - Type Unspecified
WV0201994Medicaid