1376541094 NPI number — RAYMOND LILLY JR. M.D.

Table of content: RAYMOND LILLY JR. M.D. (NPI 1376541094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376541094 NPI number — RAYMOND LILLY JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LILLY
Provider First Name:
RAYMOND
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LILLY, JR
Provider Other First Name:
R.
Provider Other Middle Name:
LINDSAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1376541094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/15/2006
NPI Reactivation Date:
03/27/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 N GRAND AVE
Provider Second Line Business Mailing Address:
STE 508
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81003-2757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-595-7040
Provider Business Mailing Address Fax Number:
719-595-7045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 N GRAND AVE
Provider Second Line Business Practice Location Address:
STE 508
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81003-2757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-595-7040
Provider Business Practice Location Address Fax Number:
719-595-7045
Provider Enumeration Date:
07/07/2005

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: 207T00000X , with the licence number:  31336 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00149591 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 01313360 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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