Healthcare Provider Details

I. General information

NPI: 1114951357
Provider Name (Legal Business Name): STEPHEN BELGRAVE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

IV. Provider business mailing address

602 W UNIVERSITY AVE
URBANA IL
61801-2530
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3170
  • Fax:
Mailing address:
  • Phone: 217-383-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0360719622
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: