Provider Demographics
NPI:1215947171
Name:PEGRAM, LORI L (MD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:PEGRAM
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 1:302 SAINT JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3506
Mailing Address - Country:US
Mailing Address - Phone:309-664-3100
Mailing Address - Fax:309-664-3027
Practice Address - Street 1:302 SAINT JOSEPH DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3506
Practice Address - Country:US
Practice Address - Phone:309-664-3100
Practice Address - Fax:309-664-3027
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072679207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2613OtherMEDICARE GROUP PTAN
ILIL2613OtherMEDICARE GROUP PTAN
ILC43452Medicare UPIN