Healthcare Provider Details

I. General information

NPI: 1184875189
Provider Name (Legal Business Name): ASSOCIATED OTOLARYNGOLOGISTS OF DECATUR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W MCKINLEY AVE 101W MCKINLEY AVE
DECATUR IL
62526-3286
US

IV. Provider business mailing address

PO BOX 2170 101W MCKINLEY AVE
DECATUR IL
62524-2170
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-3372
  • Fax: 217-876-3345
Mailing address:
  • Phone: 217-876-3372
  • Fax: 217-876-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number042006194
License Number StateIL

VIII. Authorized Official

Name: DR. STEVE MARK SOBOL
Title or Position: ENT DOCTOR
Credential:
Phone: 217-876-3372