Healthcare Provider Details

I. General information

NPI: 1902989379
Provider Name (Legal Business Name): ORTHOPAEDIC AND REHABILITATION SPECIALISTS OF CENTRAL ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2006
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W HAY ST SUITE 218
DECATUR IL
62526-6328
US

IV. Provider business mailing address

304 W HAY ST SUITE 218
DECATUR IL
62526-6328
US

V. Phone/Fax

Practice location:
  • Phone: 217-877-2088
  • Fax: 217-877-3622
Mailing address:
  • Phone: 217-877-2088
  • Fax: 217-877-3622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036-109858
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036-109943
License Number StateIL

VIII. Authorized Official

Name: DR. KENNETH TUAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 217-877-2088