=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073962577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. MICHAEL EDWARD LILES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2016
-----------------------------------------------------
Last Update Date | 06/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 528 HOGBIN RD
-----------------------------------------------------
City | MILLVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08332-5228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-265-8772
-----------------------------------------------------
Fax | 856-506-8647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 528 HOGBIN RD
-----------------------------------------------------
City | MILLVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08332-5228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-265-8772
-----------------------------------------------------
Fax | 856-506-8647
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247100000X
-----------------------------------------------------
Taxonomy Name | Radiologic Technologist
-----------------------------------------------------
License Number | 634660
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------