Provider Demographics
NPI:1215982467
Name:LILLEMOE, KEITH D
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:D
Last Name:LILLEMOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 BARNHILL DR
Mailing Address - Street 2:EM 523
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5112
Mailing Address - Country:US
Mailing Address - Phone:317-274-3086
Mailing Address - Fax:317-278-1886
Practice Address - Street 1:545 BARNHILL DR
Practice Address - Street 2:EM 523
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5112
Practice Address - Country:US
Practice Address - Phone:317-274-3086
Practice Address - Fax:317-278-1886
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1058276A174400000X
MA247458208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200460210Medicaid
IN233690ZMedicare ID - Type Unspecified
IN200460210Medicaid