Healthcare Provider Details

I. General information

NPI: 1902867997
Provider Name (Legal Business Name): K M B S C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E LAKE SHORE DR
DECATUR IL
62521-3883
US

IV. Provider business mailing address

PO BOX 790129
ST LOUIS MO
63179-0129
US

V. Phone/Fax

Practice location:
  • Phone: 217-464-2966
  • Fax: 217-464-3193
Mailing address:
  • Phone: 217-464-2966
  • Fax: 217-464-3193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUE A STRAYER
Title or Position: PRESIDENT
Credential: MD
Phone: 217-464-2966