MEDICARE: LILLY S BONTRAGER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01061077A	IN
2	207Q00000X	Family Medicine Physician	35137291	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00465447	OTHER	IN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22313	OTHER		PHYSICIANS HEALTH PLAN
3	000000518581	OTHER		BLUE CROSS BLUE SHIELD
4	000000665045	OTHER	IN	ANTHEM
5	000000039572	OTHER		MPLAN
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033120993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILLY S BONTRAGER MD

Provider Business Mailing Address
First Line	:	PO BOX 636930
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-6930
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 E 5TH ST STE 1
Second Line	:
City	:	DELPHOS
State	:	OH
Zip	:	45833-9180
Country	:	US
Telephone Number	:	419-692-5611
Fax Number	:	419-695-9401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	07/06/2020

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Directions to “ LILLY S BONTRAGER MD” Practice Location

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