Provider Demographics
NPI:1467433193
Name:LILLY, CHARLES JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:LILLY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9369
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36691-0369
Mailing Address - Country:US
Mailing Address - Phone:251-460-0326
Mailing Address - Fax:251-460-2846
Practice Address - Street 1:5 MOBILE INFIRMARY CIR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3513
Practice Address - Country:US
Practice Address - Phone:251-460-0326
Practice Address - Fax:251-460-2846
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL7261174400000X, 2085R0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological Physics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000003664Medicaid
AL000003664Medicaid
AL000003664Medicare PIN