1104858612 NPI number — MR. BUDDY WAYNE LILE M.D.

Table of content: MR. BUDDY WAYNE LILE M.D. (NPI 1104858612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104858612 NPI number — MR. BUDDY WAYNE LILE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LILE
Provider First Name:
BUDDY
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
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:
INGRAM-LILE
Provider Other First Name:
BUD
Provider Other Middle Name:
WAYNE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1104858612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 MAIN STREET
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
NEW BRIGHTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-326-7558
Provider Business Mailing Address Fax Number:
612-454-2087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
NEW BRIGHTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-326-7558
Provider Business Practice Location Address Fax Number:
612-454-2087
Provider Enumeration Date:
07/07/2006

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: 2084P0800X , with the licence number:  042-0010705 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 49329 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 042-0010705 . This is a "VERMONT STATE LICENSE" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1010386 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1010386 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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