Healthcare Provider Details

I. General information

NPI: 1770538225
Provider Name (Legal Business Name): LYLE D PAHNKE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PLEASANT AVE
CENTRALIA IL
62801-3056
US

IV. Provider business mailing address

400 N PLEASANT AVE
CENTRALIA IL
62801-3056
US

V. Phone/Fax

Practice location:
  • Phone: 618-436-6318
  • Fax: 618-436-6386
Mailing address:
  • Phone: 618-436-6318
  • Fax: 618-436-6386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036089773
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036089773
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036089773
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: