Healthcare Provider Details

I. General information

NPI: 1467074138
Provider Name (Legal Business Name): CARLE WEST PHYSICIAN GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE STE 3400
NORMAL IL
61761-6523
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 309-556-8295
  • Fax:
Mailing address:
  • Phone: 217-383-6792
  • Fax: 217-383-4752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES C LEONARD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 217-383-3468