Healthcare Provider Details

I. General information

NPI: 1346760105
Provider Name (Legal Business Name): BRETTE CAMERANN HARDING MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N BOND ST
SPRINGFIELD IL
62702-4952
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-0253
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-2101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2017019818
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036.165831
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: