Healthcare Provider Details

I. General information

NPI: 1992879126
Provider Name (Legal Business Name): OTTAWA MEDICAL CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1614 E NORRIS DR
OTTAWA IL
61350-3681
US

IV. Provider business mailing address

1614 E NORRIS DR
OTTAWA IL
61350-3681
US

V. Phone/Fax

Practice location:
  • Phone: 815-431-3265
  • Fax: 815-431-3259
Mailing address:
  • Phone: 815-431-3265
  • Fax: 815-431-3259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number9032426
License Number StateIL

VIII. Authorized Official

Name: JILL L LOWE
Title or Position: ACCOUNTING CLERK
Credential:
Phone: 815-431-3265