Healthcare Provider Details

I. General information

NPI: 1003120783
Provider Name (Legal Business Name): CARLOS ALBERTO URDININEA KIRKWOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N PROMENADE ST
HAVANA IL
62644-1243
US

IV. Provider business mailing address

PO BOX 530
HAVANA IL
62644-0530
US

V. Phone/Fax

Practice location:
  • Phone: 309-543-6600
  • Fax:
Mailing address:
  • Phone: 309-543-6600
  • Fax: 309-543-2089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125058668
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: