Provider Demographics
NPI:1275591430
Name:MUNFORD, LORELI
Entity Type:Individual
Prefix:
First Name:LORELI
Middle Name:
Last Name:MUNFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 FOREST HILLS RD
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-8234
Mailing Address - Country:US
Mailing Address - Phone:815-713-2742
Mailing Address - Fax:815-282-8597
Practice Address - Street 1:10100 FOREST HILLS RD
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-8234
Practice Address - Country:US
Practice Address - Phone:815-713-2742
Practice Address - Fax:815-282-8597
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28414207R00000X
IL036-120782207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC284141Medicaid
IL036-120782OtherILLINOIS STATE LICENSE
SC284141Medicaid
SCAA12314397Medicare ID - Type Unspecified
SCI49343Medicare UPIN
SCAA12314400Medicare ID - Type Unspecified
SCAA12314398Medicare ID - Type Unspecified