Healthcare Provider Details

I. General information

NPI: 1588736847
Provider Name (Legal Business Name): ISABELO CASTILLO, MDSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E GRANT ST UNIT 4
MACOMB IL
61455-3374
US

IV. Provider business mailing address

501 E GRANT ST UNIT 4
MACOMB IL
61455-3374
US

V. Phone/Fax

Practice location:
  • Phone: 309-837-2100
  • Fax: 309-837-5800
Mailing address:
  • Phone: 309-837-2100
  • Fax: 309-837-5800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number036089354
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ISABELO CHRISTOPHER CASTILLO
Title or Position: PRESIDENT
Credential: MD
Phone: 309-837-2100