Provider Demographics
NPI:1205824059
Name:EAGLETON, LANIE E (MD)
Entity Type:Individual
Prefix:
First Name:LANIE
Middle Name:E
Last Name:EAGLETON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19636
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9636
Mailing Address - Country:US
Mailing Address - Phone:217-545-0187
Mailing Address - Fax:217-788-5543
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:RM 0300
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4909
Practice Address - Country:US
Practice Address - Phone:217-545-5864
Practice Address - Fax:217-545-4734
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052906207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052906Medicaid
C37335Medicare UPIN
IL036052906Medicaid
ILL60169Medicare PIN