Healthcare Provider Details

I. General information

NPI: 1508932856
Provider Name (Legal Business Name): STEPHEN M LATHROP C.PED.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 N ALLEN ST SUITE A
ROBINSON IL
62454-1116
US

IV. Provider business mailing address

310 S WEBSTER ST
ROBINSON IL
62454-2837
US

V. Phone/Fax

Practice location:
  • Phone: 618-544-3595
  • Fax:
Mailing address:
  • Phone: 618-544-9220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: