MEDICARE: ERICA LANE CONRAD 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	207Q00000X	Family Medicine Physician	036158950	IL

General Provider Information

NPI Number	:	1457646028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA LANE CONRAD M.D.

Provider Business Mailing Address
First Line	:	300 SATTLEY ST
Second Line	:
City	:	ROCHESTER
State	:	IL
Zip	:	62563-9241
Country	:	US
Telephone Number	:	217-789-3630
Fax Number	:	217-498-6812

Provider Business Practice Location Address
First Line	:	300 SATTLEY ST
Second Line	:
City	:	ROCHESTER
State	:	IL
Zip	:	62563-9241
Country	:	US
Telephone Number	:	217-789-3630
Fax Number	:	217-498-6812

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

Provider Enumeration Date	:	06/13/2011
Last Update Date	:	02/08/2022

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