Healthcare Provider Details

I. General information

NPI: 1003067661
Provider Name (Legal Business Name): DANA L ALTENBURGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 FRANKLIN AVE
NORMAL IL
61761-3558
US

IV. Provider business mailing address

2163 W RAVINA PARK RD
DECATUR IL
62526-3067
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-2657
  • Fax:
Mailing address:
  • Phone: 309-268-2657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036.127294
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: