Provider Demographics
NPI:1992995179
Name:LILAH C GONZALEZ MD PA
Entity type:Organization
Organization Name:LILAH C GONZALEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LILAH
Authorized Official - Middle Name:C
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-641-2696
Mailing Address - Street 1:314 FRANKLIN AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1215
Mailing Address - Country:US
Mailing Address - Phone:410-641-2696
Mailing Address - Fax:
Practice Address - Street 1:314 FRANKLIN AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1215
Practice Address - Country:US
Practice Address - Phone:410-641-2696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD825M439FMedicare PIN
MDD76235Medicare UPIN