Basic Information
| Provider Information | |||||||||
| NPI: | 1649414657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LILLETTE A INTAPHAN MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26040 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312216040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784751299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 432 POPLAR ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312013336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784751299 | ||||||||
| FaxNumber: | 4784057928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2009 | ||||||||
| LastUpdateDate: | 10/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | INTAPHAN | ||||||||
| AuthorizedOfficialFirstName: | LILLETTE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MDC | ||||||||
| AuthorizedOfficialTelephone: | 4784751299 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 033601 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | DP2683 | 01 | GA | RR MDC | OTHER |