NPI
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NPI 1104676543
Read from the NPPES registry on October 23, 2026.
Facts
- Status
- Active
- Credential
- PHDH
- Type
- Individual
- Enumeration date
- 2024-03-26
- Last updated
- 2024-03-26
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Specialties
Licenses
- License IL
- L20014077
Location
- Practice location
- 402 E South 1st St
- City
- Herrick IL
- Postal code
- 62431-1600
- Phone
- (217) 254-2816
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
No exclusion found for this NPI in the OIG LEIE file dated October 9, 2026. Confirm on OIG's online search.
Nearby
Other NPIs in Herrick, IL. 7 records in the public file.
Public data from NPPES and CMS. Not a credentialing determination.
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