Healthcare Provider Details

I. General information

NPI: 1457350415
Provider Name (Legal Business Name): PETER LILJEBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9891 GENERAL PULLER HWY
HARTFIELD VA
23071-3122
US

IV. Provider business mailing address

9891 GENERAL PULLER HWY
HARTFIELD VA
23071-3122
US

V. Phone/Fax

Practice location:
  • Phone: 804-776-9221
  • Fax: 804-776-7537
Mailing address:
  • Phone: 804-776-9221
  • Fax: 804-776-7537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number170054-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101260392
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: