Healthcare Provider Details

I. General information

NPI: 1215982467
Provider Name (Legal Business Name): KEITH D LILLEMOE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 BARNHILL DR EM 523
INDIANAPOLIS IN
46202-5112
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-3086
  • Fax: 317-278-1886
Mailing address:
  • Phone: 410-955-5000
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number247458
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number1058276A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD0024521
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: