Provider Demographics
NPI:1629248190
Name:LILLIAN MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:LILLIAN MEDICAL CLINIC, PC
Other - Org Name:LILLIAN CONVENIENT CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DR. / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RADCLIFFE
Authorized Official - Middle Name:J
Authorized Official - Last Name:COYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:251-962-4362
Mailing Address - Street 1:PO BOX 389
Mailing Address - Street 2:
Mailing Address - City:LILLIAN
Mailing Address - State:AL
Mailing Address - Zip Code:36549-0389
Mailing Address - Country:US
Mailing Address - Phone:251-962-4362
Mailing Address - Fax:251-962-4363
Practice Address - Street 1:34463 US HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:LILLIAN
Practice Address - State:AL
Practice Address - Zip Code:36549-4049
Practice Address - Country:US
Practice Address - Phone:251-962-4362
Practice Address - Fax:251-962-4363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6346305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALG86055Medicare UPIN