Basic Information
| Provider Information | |||||||||
| NPI: | 1164479424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAGOSKI | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9401 HOLY CROSS LN | ||||||||
| Address2: | |||||||||
| City: | BREESE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622303510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185267271 | ||||||||
| FaxNumber: | 6185268248 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 NE GLEN OAK AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616360001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096248818 | ||||||||
| FaxNumber: | 3096248820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036060508 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 036060508 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036060508 | 05 | IL | MEDICAID |