Healthcare Provider Details

I. General information

NPI: 1346080322
Provider Name (Legal Business Name): DREW CONNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST STE 3100
SPRINGFIELD IL
62702-4968
US

IV. Provider business mailing address

751 N RUTLEDGE ST STE 3100
SPRINGFIELD IL
62702-4968
US

V. Phone/Fax

Practice location:
  • Phone: 217-814-5178
  • Fax: 217-757-6458
Mailing address:
  • Phone: 217-814-5178
  • Fax: 217-757-6458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number125.083932
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125083932
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: