Healthcare Provider Details

I. General information

NPI: 1205958741
Provider Name (Legal Business Name): WESTERN ILLINOIS MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 E GRANT ST
MACOMB IL
61455-3371
US

IV. Provider business mailing address

909 E GRANT ST
MACOMB IL
61455-3371
US

V. Phone/Fax

Practice location:
  • Phone: 309-837-7546
  • Fax: 312-674-7546
Mailing address:
  • Phone: 309-837-7546
  • Fax: 126-747-5463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036099467
License Number StateIL

VIII. Authorized Official

Name: DR. XIAOLU LI
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 309-837-7546