Healthcare Provider Details

I. General information

NPI: 1699748038
Provider Name (Legal Business Name): CENTRAL ILLINOIS PULMONARY & CRITICAL CARE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

132 E MOSSVILLE RD
PEORIA IL
61615-9793
US

V. Phone/Fax

Practice location:
  • Phone: 309-645-8588
  • Fax: 309-579-3011
Mailing address:
  • Phone: 309-645-8588
  • Fax: 309-579-3011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: BERNARD G TAYLOR
Title or Position: PRESIDENT
Credential: MD
Phone: 309-645-8588