Provider Demographics
NPI:1386762110
Name:LILLIE R BENNETT MD LTD
Entity type:Organization
Organization Name:LILLIE R BENNETT MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LILLIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-321-2651
Mailing Address - Street 1:2809 NORTH AVENUE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23222
Mailing Address - Country:US
Mailing Address - Phone:804-321-2651
Mailing Address - Fax:804-321-5985
Practice Address - Street 1:2809 NORTH AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23222
Practice Address - Country:US
Practice Address - Phone:804-321-2651
Practice Address - Fax:804-321-5985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101018892208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6739725Medicaid
VA6739725Medicaid