Healthcare Provider Details

I. General information

NPI: 1801839105
Provider Name (Legal Business Name): DOLORES M CANTRELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E HIGHWAY 40
TROY IL
62294-2201
US

IV. Provider business mailing address

220 E HIGHWAY 40
TROY IL
62294-2201
US

V. Phone/Fax

Practice location:
  • Phone: 618-667-1200
  • Fax: 618-667-4527
Mailing address:
  • Phone: 618-667-1200
  • Fax: 618-667-4527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036073393
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: