Healthcare Provider Details

I. General information

NPI: 1760464481
Provider Name (Legal Business Name): SURGICAL SPECIALISTS OF CENTRAL ILLINOIS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 11/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 E LAKE SHORE DR STE 200
DECATUR IL
62521-3809
US

IV. Provider business mailing address

1750 E LAKE SHORE DR STE 200
DECATUR IL
62521-3809
US

V. Phone/Fax

Practice location:
  • Phone: 217-428-6300
  • Fax: 217-428-6322
Mailing address:
  • Phone: 217-428-6300
  • Fax: 217-428-6322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: JOHN JOSEPH WHITE
Title or Position: PRESIDENT
Credential: MD
Phone: 217-428-6300