Healthcare Provider Details

I. General information

NPI: 1720073067
Provider Name (Legal Business Name): SANDRA JEAN KNUTH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N ALLEN ST
ROBINSON IL
62454-1167
US

IV. Provider business mailing address

1000 N ALLEN ST
ROBINSON IL
62454-1114
US

V. Phone/Fax

Practice location:
  • Phone: 618-544-3131
  • Fax:
Mailing address:
  • Phone: 618-544-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036085707
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: