Provider Demographics
NPI:1487649729
Name:BATES, LILLIE EDWARDS (MD)
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:EDWARDS
Last Name:BATES
Suffix:
Gender:F
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:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 W MAIN ST
Practice Address - Street 2:STE 204
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2507
Practice Address - Country:US
Practice Address - Phone:803-359-8855
Practice Address - Fax:803-359-1257
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15599208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC155995Medicaid
F70375Medicare UPIN