Provider Demographics
NPI:1437152394
Name:CHECKLEY, LORI L (MD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:L
Last Name:CHECKLEY
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 1:17231 WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-2068
Mailing Address - Country:US
Mailing Address - Phone:269-445-7295
Mailing Address - Fax:
Practice Address - Street 1:17231 WILSHIRE DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-2068
Practice Address - Country:US
Practice Address - Phone:269-445-7295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2022-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082974207Q00000X
IN01069750A207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN169380005OtherMEDICARE
IN236040010OtherMEDICARE
IN100325680Medicaid
MI104736609Medicaid
IN236040010OtherMEDICARE