Provider Demographics
NPI:1275591430
Name:MUNFORD, LORELI
Entity type:Individual
Prefix:
First Name:LORELI
Middle Name:
Last Name:MUNFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259A BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4146
Mailing Address - Country:US
Mailing Address - Phone:803-607-5449
Mailing Address - Fax:803-494-2166
Practice Address - Street 1:259A BROAD ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4146
Practice Address - Country:US
Practice Address - Phone:803-607-5449
Practice Address - Fax:803-494-2166
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-120782207R00000X
SC28414207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC284141Medicaid
IL036-120782OtherILLINOIS STATE LICENSE
SC284141Medicaid
SCAA12314397Medicare ID - Type Unspecified
SCI49343Medicare UPIN
SCAA12314400Medicare ID - Type Unspecified
SCAA12314398Medicare ID - Type Unspecified