Healthcare Provider Details

I. General information

NPI: 1841644077
Provider Name (Legal Business Name): SARA LILLY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2016
Last Update Date: 09/29/2022
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR STE A200
GREENVILLE SC
29615-3580
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-5115
  • Fax: 864-241-9205
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number82809
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: