Provider Demographics
NPI:1902899834
Name:LILLIG, MARY ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:
Last Name:LILLIG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY ANN
Other - Middle Name:
Other - Last Name:DRINKHOUSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:36123 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:913-660-1616
Mailing Address - Fax:
Practice Address - Street 1:6301 E 125TH ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-1884
Practice Address - Country:US
Practice Address - Phone:913-660-1616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-28496207R00000X
MO1999135661207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00345672OtherRAILROAD MEDICARE
MO26231025OtherBLUE SHIELD KC, MO
MO1902899834Medicaid
MO204776215Medicaid
KS100351420BMedicaid
MOP01000002Medicare PIN
KSP00345672OtherRAILROAD MEDICARE
G92147Medicare UPIN
MO204776215Medicaid