Healthcare Provider Details

I. General information

NPI: 1558241315
Provider Name (Legal Business Name): TYSON E MAGEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S KOKE MILL RD
SPRINGFIELD IL
62711-9252
US

IV. Provider business mailing address

1301 S KOKE MILL RD
SPRINGFIELD IL
62711-9252
US

V. Phone/Fax

Practice location:
  • Phone: 217-547-9100
  • Fax: 217-547-9236
Mailing address:
  • Phone: 217-547-9100
  • Fax: 217-547-9236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.604612
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.036034
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number28282759A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: