Healthcare Provider Details

I. General information

NPI: 1376853994
Provider Name (Legal Business Name): ENT & SLEEP MEDICINE ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2010
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ELEVEN S STE 4F
COLUMBIA IL
62236-1080
US

IV. Provider business mailing address

1000 ELEVEN S STE 4F
COLUMBIA IL
62236-1080
US

V. Phone/Fax

Practice location:
  • Phone: 618-628-0715
  • Fax: 888-371-4468
Mailing address:
  • Phone: 618-628-0715
  • Fax: 888-371-4468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number036101869
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036101869
License Number StateIL

VIII. Authorized Official

Name: KELLI BLAGG
Title or Position: BUSINESS MANAGER
Credential:
Phone: 618-628-0715