Healthcare Provider Details

I. General information

NPI: 1164571139
Provider Name (Legal Business Name): WOMENS HEALTH CENTER OF MACOMB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E GRANT ST SUITE 102
MACOMB IL
61455-3352
US

IV. Provider business mailing address

PO BOX 393
MACOMB IL
61455-0393
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-5959
  • Fax: 309-833-4969
Mailing address:
  • Phone: 309-833-2868
  • Fax: 309-836-3779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036102265
License Number StateIL

VIII. Authorized Official

Name: TROY D ECKMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 309-833-5959