Provider Demographics
NPI:1538132691
Name:LILLE, SEAN T (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:T
Last Name:LILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10210 N 92ND ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4509
Mailing Address - Country:US
Mailing Address - Phone:480-661-6197
Mailing Address - Fax:480-661-8146
Practice Address - Street 1:10210 N 92ND ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4509
Practice Address - Country:US
Practice Address - Phone:480-661-6197
Practice Address - Fax:480-661-8146
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ274532086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0875140OtherBLUE CROSS
AZ47965103Medicaid
AZ7492124OtherAETNA
AZZ60632Medicare ID - Type UnspecifiedMEDICARE
AZAZ0875140OtherBLUE CROSS