1508834839 NPI number — LOURDES DELGADO-SERRANO MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508834839 NPI number — LOURDES DELGADO-SERRANO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELGADO-SERRANO
Provider First Name:
LOURDES
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SERRANO
Provider Other First Name:
LOURDES
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1508834839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 ILLINI DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61605-2576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-671-8503
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DEPT OF PEDIATRICS
Provider Second Line Business Practice Location Address:
320 E ARMSTRONG
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-624-9587
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X , with the licence number:  036083077 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07215036 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036083077 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: IL01CX . This is a "JOHN DEERE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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