Healthcare Provider Details

I. General information

NPI: 1558425462
Provider Name (Legal Business Name): CENTRAL ILLINOIS ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E LAKE SHORE DR
DECATUR IL
62521-3810
US

IV. Provider business mailing address

1800 E LAKE SHORE DR
DECATUR IL
62521-3810
US

V. Phone/Fax

Practice location:
  • Phone: 217-464-5839
  • Fax: 217-464-1671
Mailing address:
  • Phone: 217-464-5839
  • Fax: 217-464-1671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SHANE FANCHER
Title or Position: PRESIDENT
Credential: MD
Phone: 217-464-5839