Healthcare Provider Details

I. General information

NPI: 1649370271
Provider Name (Legal Business Name): ROBERT CIPOLLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 KLEEMANN DR
CLINTON IL
61727-2633
US

IV. Provider business mailing address

1231 KLEEMANN DR
CLINTON IL
61727-2633
US

V. Phone/Fax

Practice location:
  • Phone: 217-935-5022
  • Fax: 217-935-9592
Mailing address:
  • Phone: 217-935-5022
  • Fax: 217-935-9592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: