Healthcare Provider Details

I. General information

NPI: 1922159110
Provider Name (Legal Business Name): JEREMY MEDLER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W. CURTIS ROAD DERMATOLOGY
CHAMPAIGN IL
61822
US

IV. Provider business mailing address

611 W PARK ST BWPC
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-6204
  • Fax: 217-326-1234
Mailing address:
  • Phone: 217-383-6792
  • Fax: 217-383-4752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number85002513
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: