Healthcare Provider Details

I. General information

NPI: 1124059506
Provider Name (Legal Business Name): ROOP LAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 W LINCOLN ST
BELLEVILLE IL
62220-1900
US

IV. Provider business mailing address

340 W LINCOLN ST
BELLEVILLE IL
62220-1900
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-6044
  • Fax: 618-233-3287
Mailing address:
  • Phone: 618-233-6044
  • Fax: 618-233-3287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036-074237
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number036074237
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: