Provider Demographics
NPI:1619969342
Name:LILLICH, JAMES S (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:S
Last Name:LILLICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1534 ELIZABETH AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4531
Mailing Address - Country:US
Mailing Address - Phone:318-629-5001
Mailing Address - Fax:318-629-5020
Practice Address - Street 1:1500 LINE AVENUE
Practice Address - Street 2:STE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-635-3052
Practice Address - Fax:318-632-6087
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA15579207XX0004X
LA015579207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA200016146Medicare PIN
LAB62059Medicare UPIN
LA5M869B103Medicare PIN
5M869B103Medicare PIN