1881742468 NPI number — PATRICK L LILLARD M.D.

Table of content: PATRICK L LILLARD M.D. (NPI 1881742468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881742468 NPI number — PATRICK L LILLARD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LILLARD
Provider First Name:
PATRICK
Provider Middle Name:
L
Provider Name Prefix Text:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881742468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 E. HOSPITAL ROAD, 12 WEST
Provider Second Line Business Mailing Address:
12 WEST
Provider Business Mailing Address City Name:
FORT GORDON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-305-7086
Provider Business Mailing Address Fax Number:
706-787-0105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 E. HOSPITAL ROAD
Provider Second Line Business Practice Location Address:
ROOM 13A-10
Provider Business Practice Location Address City Name:
FT GORDON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30905-5650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-305-7086
Provider Business Practice Location Address Fax Number:
706-787-0105
Provider Enumeration Date:
01/08/2007

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:  46721 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8951821 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130G7 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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