Healthcare Provider Details

I. General information

NPI: 1174733521
Provider Name (Legal Business Name): CHARLES ANTHONY CAVALLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3132 OLD JACKSONVILLE RD STE 110
SPRINGFIELD IL
62704-7401
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-588-2600
  • Fax: 217-862-0904
Mailing address:
  • Phone: 800-577-5368
  • Fax: 217-757-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036041159
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number258002
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-041159
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036041159
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number258002
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: