Healthcare Provider Details

I. General information

NPI: 1366558199
Provider Name (Legal Business Name): RICHARD W TWANOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 N GREENWOOD ST
SPRING VALLEY IL
61362-1576
US

IV. Provider business mailing address

600 E 1ST ST
SPRING VALLEY IL
61362-1512
US

V. Phone/Fax

Practice location:
  • Phone: 815-663-5511
  • Fax: 815-663-1528
Mailing address:
  • Phone: 815-663-5511
  • Fax: 815-663-1528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036090695
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: