Provider Demographics
NPI:1619941499
Name:LILLEHEI, THEODORE J (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:J
Last Name:LILLEHEI
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 1:280 SMITH AVE N
Mailing Address - Street 2:SUITE 311
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2424
Mailing Address - Country:US
Mailing Address - Phone:651-330-3656
Mailing Address - Fax:651-340-1160
Practice Address - Street 1:280 SMITH AVE N STE 311
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2465
Practice Address - Country:US
Practice Address - Phone:651-330-3656
Practice Address - Fax:651-340-1160
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29143174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN626878100Medicaid
MNP85178Medicare UPIN
MN626878100Medicaid