1033120993 NPI number — LILLY S BONTRAGER MD

Table of content: LILLY S BONTRAGER MD (NPI 1033120993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033120993 NPI number — LILLY S BONTRAGER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONTRAGER
Provider First Name:
LILLY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SANTELIZ
Provider Other First Name:
LILLY
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1033120993
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 636930
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45263-6930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 E 5TH ST STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELPHOS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45833-9180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-692-5611
Provider Business Practice Location Address Fax Number:
419-695-9401
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01061077A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 35137291 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22313 . This is a "PHYSICIANS HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00465447 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000518581 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000665045 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000039572 . This is a "MPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200803540 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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