Healthcare Provider Details

I. General information

NPI: 1962000513
Provider Name (Legal Business Name): MIDWEST SINUS SLEEP & ALLERGY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4224 LINCOLNSHIRE DR STE B
MOUNT VERNON IL
62864-2156
US

IV. Provider business mailing address

4224 LINCOLNSHIRE DR STE B
MOUNT VERNON IL
62864-2156
US

V. Phone/Fax

Practice location:
  • Phone: 618-816-0715
  • Fax: 888-371-4468
Mailing address:
  • Phone: 618-816-0715
  • Fax: 888-371-4468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLI BLAGG
Title or Position: OFFICE MANAGER
Credential:
Phone: 618-628-0715