MEDICARE: LILY TADAYYON KREGENOW 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
1	208000000X	Pediatrics Physician	MD00048510	WA

General Provider Information

NPI Number	:	1992766117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILY TADAYYON KREGENOW MD

Provider Business Mailing Address
First Line	:	11 GARVEY PARKWAY
Second Line	:
City	:	ST CHARLES
State	:	MD
Zip	:	63303
Country	:	US
Telephone Number	:	636-441-7280
Fax Number	:	636-939-9208

Provider Business Practice Location Address
First Line	:	316 MARTIN LUTHER KING JR WAY
Second Line	:	212
City	:	TACOMA
State	:	WA
Zip	:	98405-4252
Country	:	US
Telephone Number	:	253-383-5777
Fax Number	:	253-627-0855

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

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	09/21/2012

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