MEDICARE: DR. ALBERT CHARLES LO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	36-090682	IL
2	2084P0800X	Psychiatry Physician	S7091	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1D7195	OTHER	TX	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01032028	OTHER	IL	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396730388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALBERT CHARLES LO M.D.

Provider Business Mailing Address
First Line	:	2900 E 29TH ST
Second Line	:	STE 100
City	:	BRYAN
State	:	TX
Zip	:	77802-2623
Country	:	US
Telephone Number	:	217-355-0926
Fax Number	:	217-355-1801

Provider Business Practice Location Address
First Line	:	8441 STATE HIGHWAY 47 STE 1400
Second Line	:
City	:	BRYAN
State	:	TX
Zip	:	77807-3208
Country	:	US
Telephone Number	:	979-774-8200
Fax Number	:	877-607-5854

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	01/11/2021

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Directions to “ DR. ALBERT CHARLES LO M.D.” Practice Location

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