Provider Demographics
NPI:1649414657
Name:LILLETTE A INTAPHAN MD LLC
Entity Type:Organization
Organization Name:LILLETTE A INTAPHAN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MDC
Authorized Official - Prefix:
Authorized Official - First Name:LILLETTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:INTAPHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-475-1299
Mailing Address - Street 1:PO BOX 26040
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-6040
Mailing Address - Country:US
Mailing Address - Phone:478-475-1299
Mailing Address - Fax:
Practice Address - Street 1:432 POPLAR ST
Practice Address - Street 2:SUITE B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-3336
Practice Address - Country:US
Practice Address - Phone:478-475-1299
Practice Address - Fax:478-405-7928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033601207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADP2683OtherRR MDC
GAE62636Medicare UPIN
GA202G700242Medicare PIN