Provider Demographics
NPI:1235351818
Name:LACK, JODY HANNAH (MD)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:HANNAH
Last Name:LACK
Suffix:
Gender:F
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 19676
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9676
Mailing Address - Country:US
Mailing Address - Phone:217-545-0003
Mailing Address - Fax:217-545-7615
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:STE 4W64
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-0003
Practice Address - Fax:217-545-7615
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-122811208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036122811Medicaid
IL256510084Medicare PIN