Healthcare Provider Details

I. General information

NPI: 1275898116
Provider Name (Legal Business Name): PELE BOUTROUS DINA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 9TH ST # 4W16
SPRINGFIELD IL
62702
US

IV. Provider business mailing address

PO BOX 19676
SPRINGFIELD IL
62794-9676
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-757-6844
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-757-6844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036-138186
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: