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NPI Code Detail

MEDICARE: LACIE PETRO M.D.

MEDICARE: LACIE PETRO 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
1207Q00000XFamily Medicine Physician125-050112IL
2207Q00000XFamily Medicine Physician036119502IL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1833120OTHERILMEDICARE GROUP PTAN

General Provider Information

NPI Number : 1619189859
Entity Type Code : Individual
Provider Name (Legal Business Name) : LACIE PETRO M.D.
Provider Business Mailing Address
First Line : 611 W. PARK ST.
Second Line : FAPC
City : URBANA
State : IL
Zip : 61801
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1302 FRANKLIN AVE STE 1100
Second Line :
City : NORMAL
State : IL
Zip : 61761-0016
Country : US
Telephone Number : 309-268-5620
Fax Number : 309-661-6226
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/03/2007
Last Update Date : 02/12/2021

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