Healthcare Provider Details

I. General information

NPI: 1740544436
Provider Name (Legal Business Name): NEWERA HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2733 KOKOPELLI DR
MARION IL
62959-5213
US

IV. Provider business mailing address

2733 KOKOPELLI DR
MARION IL
62959-5213
US

V. Phone/Fax

Practice location:
  • Phone: 618-751-9045
  • Fax:
Mailing address:
  • Phone: 618-751-9045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036067057
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209000459
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209007626
License Number StateIL

VIII. Authorized Official

Name: MRS. JILL CASH
Title or Position: PARTNER
Credential: APN
Phone: 618-751-9045