Facts
- Status
- A
- Credential
- DO
- Type
- Individual
- Enumeration date
- 2006-06-16
- Last updated
- 2023-11-27
Licenses
- License IL
- 036-135963
- License MO
- 2005000792
Location
- Practice location
- 1102 N COUNTY ROAD 700
- City
- WARSAW IL
- Postal code
- 623793011
- Phone
- 217-256-4100
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.