Healthcare Provider Details

I. General information

NPI: 1255369534
Provider Name (Legal Business Name): MICHAEL J LIGHT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N 9TH ST FL 3
SPRINGFIELD IL
62702-5310
US

IV. Provider business mailing address

201 E MADISON ST
SPRINGFIELD IL
62702-5131
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberME81342
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number036.172989
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: