1457992158 NPI number — ZACKARY STEVEN LLOYD LADSON PA

Table of content: ZACKARY STEVEN LLOYD LADSON PA (NPI 1457992158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457992158 NPI number — ZACKARY STEVEN LLOYD LADSON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LADSON
Provider First Name:
ZACKARY
Provider Middle Name:
STEVEN LLOYD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457992158
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2214 N UNIVERSITY ST
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:
61604-3221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-680-7669
Provider Business Mailing Address Fax Number:
309-681-8443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3248 VANDEVER AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEKIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61554-6277
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-680-7600
Provider Business Practice Location Address Fax Number:
309-495-8698
Provider Enumeration Date:
10/03/2019

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: 363A00000X , with the licence number:  085-007283 , 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)





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