Basic Information
Provider Information | |||||||||
NPI: | 1801880976 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DRAKE | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 415 | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND | ||||||||
State: | IL | ||||||||
PostalCode: | 622490415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6188874291 | ||||||||
FaxNumber: | 6188874293 | ||||||||
Practice Location | |||||||||
Address1: | 400 CALDWELL | ||||||||
Address2: |   | ||||||||
City: | STAUNTON | ||||||||
State: | IL | ||||||||
PostalCode: | 620881173 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186352200 | ||||||||
FaxNumber: | 6186354233 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2005 | ||||||||
LastUpdateDate: | 08/08/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 0030360413131 | IL | Y |   | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
ID | Type | State | Issuer | Description | 0006000411 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 036041313 | 05 | IL |   | MEDICAID |