Basic Information
| Provider Information | |||||||||
| NPI: | 1700887916 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LILLY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PETER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 ELKRIDGE LANDING RD | ||||||||
| Address2: | |||||||||
| City: | LINTHICUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210902917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434625010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 827 LINDEN AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102258000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 08/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | D37902 | MD | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 296881900 | 05 | MD | MEDICAID |