Provider Demographics
NPI:1740241264
Name:LILES, SCOTT A (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
Last Name:LILES
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 1:3940 STEAMBOAT CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-9324
Mailing Address - Country:US
Mailing Address - Phone:734-213-4636
Mailing Address - Fax:
Practice Address - Street 1:5301 E. HURON RIVER DR.
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48106
Practice Address - Country:US
Practice Address - Phone:734-712-4108
Practice Address - Fax:734-712-4129
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069076207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4170591Medicaid
MI4301069076OtherMEDICAL LICENSE
MI4170591Medicaid
MI0P02850001Medicare PIN