Healthcare Provider Details

I. General information

NPI: 1033195847
Provider Name (Legal Business Name): LUCAS C POGUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 03/31/2023
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 EASTLAND DR
BLOOMINGTON IL
61701-3552
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-8311
  • Fax: 309-661-3390
Mailing address:
  • Phone: 309-663-8311
  • Fax: 309-661-3390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036103017
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036103017
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: