Provider Demographics
NPI:1740249317
Name:HARGROVE, LILY WISE (MD)
Entity type:Individual
Prefix:DR
First Name:LILY
Middle Name:WISE
Last Name:HARGROVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2 BOARS HEAD PL
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-4677
Mailing Address - Country:US
Mailing Address - Phone:434-202-7830
Mailing Address - Fax:434-202-7823
Practice Address - Street 1:2 BOARS HEAD PL
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4677
Practice Address - Country:US
Practice Address - Phone:434-202-7830
Practice Address - Fax:434-202-7823
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101057199207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA540261840OtherTRICARE
VA010142105OtherVA PREMIER/UNICARE
VA010142105Medicaid
VA7988480003OtherCIGNA
VA260216OtherSO HEALTH
VAP00233742OtherPALMETTO GBA RAILROAD
VA176102OtherANTHEM SERVICES HEALTHKEE
VA2131900OtherMAMSI
VA94928OtherSENTARA
VA176102OtherANTHEM
VA540261840OtherVHN
VA010142105Medicaid
VA2131900OtherMAMSI