Healthcare Provider Details

I. General information

NPI: 1093804866
Provider Name (Legal Business Name): THOMAS LILLIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 S BROADWAY ST. JOSEPHS MEDICAL CENTER
YONKERS NY
10701-4006
US

IV. Provider business mailing address

2 CATHARINE ST P.O. BOX 550
POUGHKEEPSIE NY
12601-3100
US

V. Phone/Fax

Practice location:
  • Phone: 914-378-7000
  • Fax: 845-790-2675
Mailing address:
  • Phone: 866-868-8417
  • Fax: 845-790-2675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number432918-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: