Healthcare Provider Details

I. General information

NPI: 1033866801
Provider Name (Legal Business Name): CARLE WEST PHYSICIAN GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 03/02/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TRINITY LN STE 111
BLOOMINGTON IL
61704-8112
US

IV. Provider business mailing address

3310 FIELDS SOUTH DR FAPC
CHAMPAIGN IL
61822-3741
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-6461
  • Fax:
Mailing address:
  • Phone: 217-902-5291
  • Fax: 217-902-7711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JAMES C LEONARD
Title or Position: PRESIDENT
Credential:
Phone: 217-902-5291