Basic Information
| Provider Information | |||||||||
| NPI: | 1013006154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LILLY | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | ZVITKOVITZ | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 418 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PENN YAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145271070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157874000 | ||||||||
| FaxNumber: | 3155360430 | ||||||||
| Practice Location | |||||||||
| Address1: | 418 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PENN YAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145271070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157874000 | ||||||||
| FaxNumber: | 3155360430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 04/28/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 219816 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2108056 | 05 | NY | MEDICAID | 2589769 | 01 | NY | GHI | OTHER | P010219816 | 01 | NY | BLUE CHOICE | OTHER | 219816-6 | 01 | NY | WORKER'S COMP | OTHER | P010219816 | 01 | NY | BLUE SHIELD | OTHER | 16832BJ | 01 | NY | PREFERRED CARE | OTHER |