Basic Information
| Provider Information | |||||||||
| NPI: | 1033120993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONTRAGER | ||||||||
| FirstName: | LILLY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANTELIZ | ||||||||
| OtherFirstName: | LILLY | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 636930 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 E 5TH ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | DELPHOS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458339180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196925611 | ||||||||
| FaxNumber: | 4196959401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 07/06/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01061077A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35137291 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 22313 | 01 | PHYSICIANS HEALTH PLAN | OTHER | P00465447 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000518581 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 000000665045 | 01 | IN | ANTHEM | OTHER | 000000039572 | 01 | MPLAN | OTHER | 200803540 | 05 | IN | MEDICAID |