Provider Demographics
NPI:1932316536
Name:TIMOTHY J. LILLY, D.O. & ASSOC
Entity Type:Organization
Organization Name:TIMOTHY J. LILLY, D.O. & ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:724-615-9193
Mailing Address - Street 1:432 HILLCREST AVE
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-1730
Mailing Address - Country:US
Mailing Address - Phone:724-615-9193
Mailing Address - Fax:724-458-6689
Practice Address - Street 1:432 HILLCREST AVE
Practice Address - Street 2:SUITE ONE
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-1730
Practice Address - Country:US
Practice Address - Phone:724-615-9193
Practice Address - Fax:724-458-6689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006328L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011775800010Medicaid
PA116441W42Medicare PIN
PA0011775800010Medicaid