Provider Demographics
NPI:1770538225
Name:PAHNKE, LYLE D JR (MD)
Entity type:Individual
Prefix:
First Name:LYLE
Middle Name:D
Last Name:PAHNKE
Suffix:JR
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 1:400 N PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3056
Mailing Address - Country:US
Mailing Address - Phone:618-436-6318
Mailing Address - Fax:618-436-6386
Practice Address - Street 1:400 N PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3056
Practice Address - Country:US
Practice Address - Phone:618-436-6318
Practice Address - Fax:618-436-6386
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089773207Q00000X, 208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCG2264OtherRR GROUP NUMBER
IL207988OtherGROUP
IL036089773Medicaid
ILP00169541OtherRR MEDICARE NUMBER
IL036089773Medicaid
ILCG2264OtherRR GROUP NUMBER