Provider Demographics
NPI:1770681629
Name:LINDAHL, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:LINDAHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604
Mailing Address - Country:US
Mailing Address - Phone:309-680-7600
Mailing Address - Fax:309-681-8620
Practice Address - Street 1:320 E ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-681-8443
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-061295207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061295Medicaid
IL809870Medicare ID - Type UnspecifiedGROUP #
ILL29203Medicare ID - Type UnspecifiedINDIVIDUAL #
ILL62736Medicare ID - Type UnspecifiedINDIVIDUAL #
IL036061295Medicaid
C45559Medicare UPIN