Healthcare Provider Details

I. General information

NPI: 1639864788
Provider Name (Legal Business Name): LILLY SU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 HOLLAND ST
SOMERVILLE MA
02144-2705
US

IV. Provider business mailing address

75 GARDNER ST APT 25
ALLSTON MA
02134-2203
US

V. Phone/Fax

Practice location:
  • Phone: 617-629-6000
  • Fax:
Mailing address:
  • Phone: 443-593-8423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1026735
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number1026735
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: