Provider Demographics
NPI:1962799486
Name:LILY OBSTETRICS AND GYNECOLOGY, LLC
Entity type:Organization
Organization Name:LILY OBSTETRICS AND GYNECOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:F
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-638-1801
Mailing Address - Street 1:7000 WELLNESS WAY
Mailing Address - Street 2:SUITE 7220
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2286
Mailing Address - Country:US
Mailing Address - Phone:912-638-1801
Mailing Address - Fax:912-638-1821
Practice Address - Street 1:7000 WELLNESS WAY
Practice Address - Street 2:SUITE 7220
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2286
Practice Address - Country:US
Practice Address - Phone:912-638-1801
Practice Address - Fax:912-638-1821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-05
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050041207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003118614AMedicaid
GA003118614AMedicaid
GA202G490852Medicare PIN