Basic Information
| Provider Information | |||||||||
| NPI: | 1003166612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LILLEY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | RAYMOND | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 NE NEFF RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413823344 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2200 NE NEFF RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413823344 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2012 | ||||||||
| LastUpdateDate: | 05/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 178069 | OR | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 178069 | 01 | OR | OREGON MEDICAL BOARD | OTHER | 60659856 | 01 | WA | WASHINGTON MEDICAL BOARD | OTHER | 122323 | 01 | CA | CALIFORNIA MEDICAL BOARD | OTHER | 500730702 | 05 | OR | MEDICAID |