Healthcare Provider Details

I. General information

NPI: 1588653935
Provider Name (Legal Business Name): RENEE ALWAN PERCELL P.A.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RENEE ALWAN

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 09/20/2010
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

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3000
  • Fax: 309-664-3026
Mailing address:
  • Phone: 309-664-3000
  • Fax: 309-664-3026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3289
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: