Healthcare Provider Details

I. General information

NPI: 1205817699
Provider Name (Legal Business Name): KENNETH WILLIAM LILIK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 MULBERRY ST
SCRANTON PA
18503-1230
US

IV. Provider business mailing address

3 W OLIVE ST SUITE 201
SCRANTON PA
18508-2572
US

V. Phone/Fax

Practice location:
  • Phone: 570-961-3933
  • Fax: 570-342-4318
Mailing address:
  • Phone: 570-961-9947
  • Fax: 570-341-5043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD026664E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberMD026664E
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberMD026664E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001034077001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: