Provider Demographics
NPI:1457350415
Name:LILJEBERG, PETER (MD)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:LILJEBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9891 GENERAL PULLER HWY
Mailing Address - Street 2:
Mailing Address - City:HARTFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23071-3122
Mailing Address - Country:US
Mailing Address - Phone:804-776-9221
Mailing Address - Fax:804-776-7537
Practice Address - Street 1:9891 GENERAL PULLER HWY
Practice Address - Street 2:
Practice Address - City:HARTFIELD
Practice Address - State:VA
Practice Address - Zip Code:23071-3122
Practice Address - Country:US
Practice Address - Phone:804-776-9221
Practice Address - Fax:804-776-7537
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170054-1207Q00000X
VA0101260392207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05379Medicare PIN
VAC05382Medicare PIN
VAC05381Medicare PIN
VAC05380Medicare PIN
VAC05382OtherGROUP PTAN
VAC05381OtherGROUP PTAN
E47461Medicare UPIN
VAC05379OtherGROUP PTAN
NYU70033Medicare ID - Type Unspecified