Healthcare Provider Details

I. General information

NPI: 1467951640
Provider Name (Legal Business Name): CEPAMERICA ILLINOIS LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT ELIZABETH BLVD
O FALLON IL
62269-1099
US

IV. Provider business mailing address

1601 CUMMINS DR STE D
MODESTO CA
95358-6411
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-2120
  • Fax:
Mailing address:
  • Phone: 510-350-2680
  • Fax: 510-879-9074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID BIRDSALL
Title or Position: ADMINISTRATIVE VP OF OPERATIONS
Credential: MD
Phone: 510-350-2600