Provider Demographics
NPI:1811983489
Name:LAL, ROBY ADHINAYAK (DO)
Entity type:Individual
Prefix:
First Name:ROBY
Middle Name:ADHINAYAK
Last Name:LAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:ADHINAYAK
Other - Middle Name:ROBY
Other - Last Name:LAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:221 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61636-0002
Mailing Address - Country:US
Mailing Address - Phone:309-672-5702
Mailing Address - Fax:309-671-2774
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0002
Practice Address - Country:US
Practice Address - Phone:309-672-5702
Practice Address - Fax:309-671-2774
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007227L2085R0001X
IL036-1160072085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361160072Medicaid
ILCM5868OtherRAILROAD MEDICARE
PA001522959Medicaid
P00334468OtherRAILROAD MEDICARE PIN
P00609726OtherRAILROAD MEDICARE PART B PTAN
IL014885OtherHEALTH ALLIANCE INS.
ILCM5868OtherRAILROAD MEDICARE
122008Medicare ID - Type Unspecified
IL0361160072Medicaid
ILK29888Medicare PIN