Healthcare Provider Details

I. General information

NPI: 1659489250
Provider Name (Legal Business Name): WILLIAM R BUCKLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S MAIN ST
CANTON IL
61520-2608
US

IV. Provider business mailing address

180 S MAIN ST
CANTON IL
61520-2608
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-0201
  • Fax: 309-647-9652
Mailing address:
  • Phone: 309-647-0201
  • Fax: 309-649-5302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0360851714
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: