Provider Demographics
NPI:1548212517
Name:LINDELL, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:LINDELL
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 1:19 OLT AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6216
Mailing Address - Country:US
Mailing Address - Phone:309-353-6301
Mailing Address - Fax:309-353-1555
Practice Address - Street 1:19 OLT AVE
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6216
Practice Address - Country:US
Practice Address - Phone:309-353-6301
Practice Address - Fax:309-353-1555
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075387207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110154966OtherRAIL ROAD MEDICARE
IL09015685OtherBLUE CROSS BLUE SHIELD
IL036075387Medicaid
IL036075387Medicaid
IL110154966OtherRAIL ROAD MEDICARE