Basic Information
| Provider Information | |||||||||
| NPI: | 1457749079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERCADO | ||||||||
| FirstName: | LLOYD | ||||||||
| MiddleName: | |||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3603 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605223603 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2331 W CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606224723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737727858 | ||||||||
| FaxNumber: | 7732766668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2015 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209012347 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 209-012347 | 05 | IL | MEDICAID | 13677101 | 01 | IL | CAQH | OTHER | MM3756890 | 01 | IL | DEA | OTHER |