Healthcare Provider Details

I. General information

NPI: 1104848332
Provider Name (Legal Business Name): MICHAEL JOHN SANDERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 W GARFIELD AVE
BARTONVILLE IL
61607-1755
US

IV. Provider business mailing address

1506 W GARFIELD AVE
BARTONVILLE IL
61607-1755
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 309-697-2416
  • Fax: 309-697-2749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.143601
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA60297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: