Healthcare Provider Details

I. General information

NPI: 1275515561
Provider Name (Legal Business Name): CRAIG S VINCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CRAIG S VINCH MD

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 W LINCOLN ST STE. 400
BELLEVILLE IL
62220-1900
US

IV. Provider business mailing address

340 W LINCOLN ST STE. 400
BELLEVILLE IL
62220-1900
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-6044
  • Fax: 618-233-5195
Mailing address:
  • Phone: 618-233-6044
  • Fax: 618-233-5195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number160974
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036136030
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: