Provider Demographics
NPI:1336277557
Name:LO, ADOLF M (MD)
Entity Type:Individual
Prefix:DR
First Name:ADOLF
Middle Name:M
Last Name:LO
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 1:208 E SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-5462
Mailing Address - Country:US
Mailing Address - Phone:217-352-2212
Mailing Address - Fax:217-352-2215
Practice Address - Street 1:208 E SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-5462
Practice Address - Country:US
Practice Address - Phone:217-352-2212
Practice Address - Fax:217-352-2215
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1000280OtherBLUE SHIELD
IL207901Medicare ID - Type UnspecifiedPROVIDER NUMBER
IL1000280OtherBLUE SHIELD