Healthcare Provider Details

I. General information

NPI: 1205181906
Provider Name (Legal Business Name): PETER MARTIN STOLL LAT, EMT-B
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3631 S 6TH ST SUITE B
SPRINGFIELD IL
62703-4777
US

IV. Provider business mailing address

3631 S 6TH ST SUITE B
SPRINGFIELD IL
62703-4777
US

V. Phone/Fax

Practice location:
  • Phone: 217-744-7529
  • Fax: 217-529-0988
Mailing address:
  • Phone: 217-744-7529
  • Fax: 217-529-0988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.000201
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: