Healthcare Provider Details

I. General information

NPI: 1952351546
Provider Name (Legal Business Name): CENTRAL ILLINOIS ALLERGY AND RESPIRATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 W MILLER ST
SPRINGFIELD IL
62702-4978
US

IV. Provider business mailing address

543 W MILLER ST
SPRINGFIELD IL
62702-4978
US

V. Phone/Fax

Practice location:
  • Phone: 217-522-5596
  • Fax: 217-522-5599
Mailing address:
  • Phone: 217-522-5596
  • Fax: 217-522-5599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. GLENNON H PAUL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 217-522-5596