Healthcare Provider Details

I. General information

NPI: 1689946022
Provider Name (Legal Business Name): CARLE FOUNDATION PHYSICIAN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N KELLER DR SUITES 3 & 4
EFFINGHAM IL
62401-1881
US

IV. Provider business mailing address

602 W UNIVERSITY AVE PROVIDER ENROLLMENT - NCW4
URBANA IL
61801-2530
US

V. Phone/Fax

Practice location:
  • Phone: 217-347-6400
  • Fax:
Mailing address:
  • Phone: 217-383-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JAMES C LEONARD
Title or Position: CEO
Credential: MD
Phone: 217-326-4677