Provider Demographics
NPI:1275935934
Name:LILLY, GLEN NEAL II (PA-C)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:NEAL
Last Name:LILLY
Suffix:II
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-0640
Mailing Address - Country:US
Mailing Address - Phone:301-373-7100
Mailing Address - Fax:301-373-6100
Practice Address - Street 1:24035 THREE NOTCH RD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:MD
Practice Address - Zip Code:20636-4871
Practice Address - Country:US
Practice Address - Phone:301-373-7100
Practice Address - Fax:301-373-6100
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0009583363A00000X
SCTL2189363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD216982700Medicaid
SC2189OtherMEDICAL LICENSE