Healthcare Provider Details

I. General information

NPI: 1295804722
Provider Name (Legal Business Name): JAIME HUMBERTO CERCONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W MILTON AVE
LEWISTOWN IL
61542-1322
US

IV. Provider business mailing address

501 W MILTON AVE
LEWISTOWN IL
61542-1322
US

V. Phone/Fax

Practice location:
  • Phone: 309-547-2135
  • Fax: 309-547-1560
Mailing address:
  • Phone: 309-547-2135
  • Fax: 309-547-1560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: