Healthcare Provider Details

I. General information

NPI: 1588643902
Provider Name (Legal Business Name): BRAD C ALBERTINI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 4TH ST
SPRINGFIELD IL
62702-5238
US

IV. Provider business mailing address

PO BOX 19670
SPRINGFIELD IL
62794-9670
US

V. Phone/Fax

Practice location:
  • Phone: 217-757-8100
  • Fax: 217-747-1351
Mailing address:
  • Phone: 217-757-8100
  • Fax: 217-747-1351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number85001668
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-001668
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: