Provider Demographics
NPI:1679539563
Name:PECK, LISA MERLE (MD)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MERLE
Last Name:PECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MERLE
Other - Last Name:PECK-ROSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3220 W IL ROUTE 60
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060
Mailing Address - Country:US
Mailing Address - Phone:847-837-8442
Mailing Address - Fax:847-837-8542
Practice Address - Street 1:350 S WAUKEGAN RD STE 100&200
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5239
Practice Address - Country:US
Practice Address - Phone:847-535-7157
Practice Address - Fax:224-271-4332
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-086705207R00000X
IL036086705207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086705Medicaid
IL036-086705Medicaid