Provider Demographics
NPI:1386630002
Name:LILLER, A. MELINDA (MD)
Entity Type:Individual
Prefix:
First Name:A.
Middle Name:MELINDA
Last Name:LILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:MELINDA
Other - Last Name:LILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:70 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-334-6071
Mailing Address - Fax:219-738-6714
Practice Address - Street 1:70 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4928
Practice Address - Country:US
Practice Address - Phone:573-334-6071
Practice Address - Fax:219-738-6714
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210145892085R0202X
IN010372352085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100258260Medicaid
IN100258260Medicaid
INC43915Medicare UPIN
INM400056185Medicare PIN
IN234800OMedicare PIN