Facts
- Status
- A
- Credential
- APN
- Type
- Individual
- Enumeration date
- 2015-03-28
- Last updated
- 2026-05-19
Specialties
Licenses
- License IL
- 277002107
Location
- Practice location
- 201 S 14TH ST
- City
- HERRIN IL
- Postal code
- 629483631
- Phone
- 618-942-2171
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.