Healthcare Provider Details

I. General information

NPI: 1215996582
Provider Name (Legal Business Name): LANNY R. SOUTH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21120 WASHINGTON PKWY
FRANKFORT IL
60423-3112
US

IV. Provider business mailing address

21120 WASHINGTON PKWY
FRANKFORT IL
60423-3112
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-9750
  • Fax:
Mailing address:
  • Phone: 815-469-9750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS7770
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number34.006388
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036.131960
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: