Provider Demographics
NPI:1619189859
Name:PETRO, LACIE (MD)
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:PETRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LACIE
Other - Middle Name:
Other - Last Name:SHANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1302 FRANKLIN AVE STE 1100
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-0016
Practice Address - Country:US
Practice Address - Phone:309-268-5620
Practice Address - Fax:309-661-6226
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-050112207Q00000X
IL036119502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL833120OtherMEDICARE GROUP PTAN
ILK52519Medicare PIN