Provider Demographics
NPI:1669427688
Name:LILLESTOL, MICHAEL JOHN (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:LILLESTOL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 GOLD DR
Mailing Address - Street 2:STE 101
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6413
Mailing Address - Country:US
Mailing Address - Phone:701-280-2033
Mailing Address - Fax:701-232-5578
Practice Address - Street 1:1707 GOLD DR
Practice Address - Street 2:STE 101
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6413
Practice Address - Country:US
Practice Address - Phone:701-280-2033
Practice Address - Fax:701-232-5578
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND4830207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDD26082OtherND WORKERS COMP
ND14165Medicaid
ND162D9LIOtherMINNESOTA BLUE SHIELD
ND21574OtherND BLUE SHIELD
1008297OtherPREFERRED ONE
116742OtherUCARE
04-12025OtherMEDICA
MN663288200Medicaid
ND4830OtherCHAMPUS
141875400OtherFEDERAL WORKERS COMP
110244424Medicare ID - Type UnspecifiedRAILROAD MEDICARE
141875400OtherFEDERAL WORKERS COMP
D26082Medicare UPIN