Healthcare Provider Details

I. General information

NPI: 1902911431
Provider Name (Legal Business Name): EFFINGHAM UROLOGY ASSOCIATES,S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 W VIRGINIA AVE
EFFINGHAM IL
62401-2258
US

IV. Provider business mailing address

414 W VIRGINIA AVE P O BOX 1169
EFFINGHAM IL
62401-2258
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-9738
  • Fax: 217-342-9806
Mailing address:
  • Phone: 217-342-9738
  • Fax: 217-342-9806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number042003881
License Number StateIL

VIII. Authorized Official

Name: DR. PERNANKEL D L NAYAK
Title or Position: OWNER
Credential: M.D.
Phone: 217-342-9738