Provider Demographics
NPI:1760477004
Name:DALE, LYNN RAOUL (MD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:RAOUL
Last Name:DALE
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 1:1000 HEALTH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-9253
Mailing Address - Country:US
Mailing Address - Phone:217-258-2141
Mailing Address - Fax:217-528-2336
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9253
Practice Address - Country:US
Practice Address - Phone:217-258-2141
Practice Address - Fax:217-528-2336
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360442632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036044263Medicaid
IL036044263Medicaid
ILP04430Medicare ID - Type Unspecified