Provider Demographics
NPI:1700887916
Name:LILLY, MICHAEL PETER (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PETER
Last Name:LILLY
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 1:920 ELKRIDGE LANDING RD
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM
Mailing Address - State:MD
Mailing Address - Zip Code:21090-2917
Mailing Address - Country:US
Mailing Address - Phone:443-462-5010
Mailing Address - Fax:
Practice Address - Street 1:827 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201
Practice Address - Country:US
Practice Address - Phone:410-225-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD379022086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD296881900Medicaid
C90147Medicare ID - Type Unspecified