Provider Demographics
NPI:1790718971
Name:LILE, LAURA (MD RPH)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:LILE
Suffix:
Gender:F
Credentials:MD RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7185 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-2450
Mailing Address - Country:US
Mailing Address - Phone:678-381-1420
Mailing Address - Fax:734-301-3209
Practice Address - Street 1:7185 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-2450
Practice Address - Country:US
Practice Address - Phone:678-381-1420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081315207Q00000X
TNMD0000047548207Q00000X
SC39945207Q00000X
OH35.082537207Q00000X
CA165125207Q00000X
GA65375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2436920Medicaid
MI7476538OtherAETNA
MI04366OtherPARAMOUNT
MI0805810112OtherBLUE CROSS BLUE SHIELD
MI0581011OtherBLUE CARE NETWORK
MI4526808Medicaid
MI0805810112OtherBLUE CROSS BLUE SHIELD
MI7476538OtherAETNA