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NPI Code Detail

MEDICARE: ALBERT JACKSON LILLY III MD

MEDICARE: ALBERT JACKSON LILLY III MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207P00000XEmergency Medicine PhysicianMD22604OR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1285677955
Entity Type Code : Individual
Provider Name (Legal Business Name) : ALBERT JACKSON LILLY III MD
Provider Business Mailing Address
First Line : PO BOX 5579
Second Line :
City : BEND
State : OR
Zip : 97708-5579
Country : US
Telephone Number : 541-706-3700
Fax Number : 541-706-3730
Provider Business Practice Location Address
First Line : 61250 SE COOMBS PL
Second Line :
City : BEND
State : OR
Zip : 97702-3704
Country : US
Telephone Number : 541-706-5930
Fax Number : 541-706-5931
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/13/2006
Last Update Date : 04/17/2020

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