Provider Demographics
NPI:1063430668
Name:LILLY, MICHAEL H (AA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:LILLY
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5203
Mailing Address - Country:US
Mailing Address - Phone:216-286-6260
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67-000016367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000232168OtherUNISON
OH415001OtherWELLCARE MEDICAID
OH0583328OtherBCMH
OH2749780Medicaid
OHP00398032OtherMEDICARE RAILROAD
OH000000515969OtherANTHEM
OH430037561OtherRAILROAD MEDICARE
OH7818960OtherAETNA
OH000000232168OtherUNISON
OHLI7239231Medicare PIN