Healthcare Provider Details

I. General information

NPI: 1396701009
Provider Name (Legal Business Name): SEBASTIEN SIMON KAIROUZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W MCKINLEY AVE SUITE 1
DECATUR IL
62526-5858
US

IV. Provider business mailing address

210 W MCKINLEY AVE SUITE 1
DECATUR IL
62526-5858
US

V. Phone/Fax

Practice location:
  • Phone: 217-877-9442
  • Fax: 217-233-1670
Mailing address:
  • Phone: 217-877-9442
  • Fax: 217-233-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberD0067931
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036128725
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: