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: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-502-2037
  • Fax:
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: