Provider Demographics
NPI:1396873725
Name:LALLY, THOMAS CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CHARLES
Last Name:LALLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:82 FORD DR
Mailing Address - Street 2:
Mailing Address - City:EAST DUBUQUE
Mailing Address - State:IL
Mailing Address - Zip Code:61025-8510
Mailing Address - Country:US
Mailing Address - Phone:815-747-6295
Mailing Address - Fax:
Practice Address - Street 1:3123 PASADENA CT
Practice Address - Street 2:UNIT 39
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-0846
Practice Address - Country:US
Practice Address - Phone:563-556-2097
Practice Address - Fax:563-556-1570
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA201602085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA03771Medicare UPIN