Provider Demographics
NPI:1376541094
Name:LILLY, RAYMOND JR (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:LILLY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:R.
Other - Middle Name:LINDSAY
Other - Last Name:LILLY, JR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1600 N GRAND AVE
Mailing Address - Street 2:STE 508
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2757
Mailing Address - Country:US
Mailing Address - Phone:719-595-7040
Mailing Address - Fax:719-595-7045
Practice Address - Street 1:1600 N GRAND AVE
Practice Address - Street 2:STE 508
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2757
Practice Address - Country:US
Practice Address - Phone:719-595-7040
Practice Address - Fax:719-595-7045
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-10-12
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
CO31336207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00149591OtherRAILROAD MEDICARE
CO01313360Medicaid
CO01313360Medicaid
COC54161Medicare PIN