Provider Demographics
NPI:1619028008
Name:LILLY WILEN M.D. A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LILLY WILEN M.D. A MEDICAL CORPORATION
Other - Org Name:NEW CONCEPTS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LILLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-831-3227
Mailing Address - Street 1:17075 DEVONSHIRE ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1600
Mailing Address - Country:US
Mailing Address - Phone:818-831-3227
Mailing Address - Fax:818-831-3447
Practice Address - Street 1:17075 DEVONSHIRE ST
Practice Address - Street 2:SUITE 306
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-1600
Practice Address - Country:US
Practice Address - Phone:818-831-3228
Practice Address - Fax:818-831-3447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61876261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty