Healthcare Provider Details

I. General information

NPI: 1063497659
Provider Name (Legal Business Name): MARY COLLEEN BINGHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 11/22/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 N MERCHANT ST
EFFINGHAM IL
62401-2128
US

IV. Provider business mailing address

PO BOX 665
EFFINGHAM IL
62401-0665
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-7000
  • Fax: 217-342-7002
Mailing address:
  • Phone: 217-342-7000
  • Fax: 217-342-7002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036089053
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: