Healthcare Provider Details

I. General information

NPI: 1093425399
Provider Name (Legal Business Name): PERSONIC WOUND CARE ILLINOIS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2022
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CHATHAM RD STE R
SPRINGFIELD IL
62704-4188
US

IV. Provider business mailing address

2501 CHATHAM RD STE R
SPRINGFIELD IL
62704-4188
US

V. Phone/Fax

Practice location:
  • Phone: 251-901-3011
  • Fax: 888-557-9724
Mailing address:
  • Phone: 251-901-3011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SYED NAQVI
Title or Position: OWNER
Credential:
Phone: 251-901-3011