Healthcare Provider Details

I. General information

NPI: 1457629842
Provider Name (Legal Business Name): OTIS ALLEN MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 HOLIDAY DR
BLOOMINGTON IL
61704-2214
US

IV. Provider business mailing address

1215 HOLIDAY DR
BLOOMINGTON IL
61704-2214
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-3881
  • Fax: 309-661-0234
Mailing address:
  • Phone: 309-827-3881
  • Fax: 309-661-0234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number036064804
License Number StateIL

VIII. Authorized Official

Name: MRS. MARGARET A. ALLEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 309-827-3881