Healthcare Provider Details

I. General information

NPI: 1275028300
Provider Name (Legal Business Name): PHILIP JAMES MEAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2018
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S MAIN ST
CANTON IL
61520-2608
US

IV. Provider business mailing address

3402 N PEORIA AVE
PEORIA IL
61603-1124
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5682
  • Fax: 309-672-3147
Mailing address:
  • Phone: 912-507-2079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125071877
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036156939
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036156939
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: