Healthcare Provider Details

I. General information

NPI: 1831301282
Provider Name (Legal Business Name): DAVID T. CROSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2007
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 W ADAMS ST
MORTON IL
61550-1802
US

IV. Provider business mailing address

PO BOX 19248
SPRINGFIELD IL
62794-9248
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-7541
  • Fax: 309-676-6545
Mailing address:
  • Phone: 217-528-7541
  • Fax: 217-525-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036118871
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: