Healthcare Provider Details

I. General information

NPI: 1639318645
Provider Name (Legal Business Name): MARTY CAUDLE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 DURLEY ST
GREENVILLE IL
62246
US

IV. Provider business mailing address

404 DURLEY ST
GREENVILLE IL
62246-1504
US

V. Phone/Fax

Practice location:
  • Phone: 618-690-3595
  • Fax: 618-690-3596
Mailing address:
  • Phone: 186-903-5956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4854
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01451
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: