Healthcare Provider Details

I. General information

NPI: 1548284979
Provider Name (Legal Business Name): THOMAS L MINOGUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LERNA ROAD SOUTH
MATTOON IL
61938
US

IV. Provider business mailing address

611 W. PARK ST. BWPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-5900
  • Fax: 217-258-5904
Mailing address:
  • Phone: 217-383-6792
  • Fax: 217-383-4752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036041833
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: