Healthcare Provider Details

I. General information

NPI: 1457348401
Provider Name (Legal Business Name): JAN RAKINIC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W CARPENTER ST 2ND FLOOR
SPRINGFIELD IL
62702-4901
US

IV. Provider business mailing address

PO BOX 19638
SPRINGFIELD IL
62794-9638
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-1025
  • Fax: 217-545-0952
Mailing address:
  • Phone: 217-545-1025
  • Fax: 217-545-0952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number036070904
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: