MEDICARE: BETHANY WILEY LILL

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
1	363A00000X	Physician Assistant
2	363AS0400X	Surgical Physician Assistant	006629	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20I2973206	OTHER	GA	MEDICARE PTAN

General Provider Information

NPI Number	:	1316298953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETHANY WILEY LILL

Provider Business Mailing Address
First Line	:	300 TOWER RD NE
Second Line	:	SUITE 200
City	:	MARIETTA
State	:	GA
Zip	:	30060-9404
Country	:	US
Telephone Number	:	770-427-5717
Fax Number	:	770-514-6744

Provider Business Practice Location Address
First Line	:	720 TRANSIT AVE
Second Line	:	SUITE 202
City	:	CANTON
State	:	GA
Zip	:	30114-2540
Country	:	US
Telephone Number	:	770-427-5717
Fax Number	:	770-514-6744

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2012
Last Update Date	:	08/27/2014

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Directions to “ BETHANY WILEY LILL ” Practice Location

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