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NPI Code Detail

MEDICARE: DEVELOPMENTAL SPECIALISTS OF SOUTHEASTERN IL, INC.

MEDICARE: DEVELOPMENTAL SPECIALISTS OF SOUTHEASTERN IL, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QD1600XDevelopmental Disabilities Clinic/CenterIL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
18030288OTHERILBLUECROSS/BLUE SHIELD IL

General Provider Information

NPI Number : 1073628350
Entity Type Code : Organization
Provider Name (Legal Business Name) : DEVELOPMENTAL SPECIALISTS OF SOUTHEASTERN IL, INC.
Provider Business Mailing Address
First Line : 905 E MAIN ST
Second Line :
City : OLNEY
State : IL
Zip : 62450-2623
Country : US
Telephone Number : 618-393-7732
Fax Number : 618-395-3123
Provider Business Practice Location Address
First Line : 905 E MAIN ST
Second Line :
City : OLNEY
State : IL
Zip : 62450-2623
Country : US
Telephone Number : 618-393-7732
Fax Number : 618-395-3123
Authorized Official
Title or Position : PRESIDENT
Name : CATHERINE ROSS
Credential :
Telephone Number : 618-393-7732
Provider Enumeration Date : 08/20/2006
Last Update Date : 04/09/2009

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