Healthcare Provider Details

I. General information

NPI: 1295855088
Provider Name (Legal Business Name): CARLE CLINIC ASSOCIATION, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E SOUTHLINE RD
TUSCOLA IL
61953-2014
US

IV. Provider business mailing address

301 E SOUTHLINE RD
TUSCOLA IL
61953-2014
US

V. Phone/Fax

Practice location:
  • Phone: 217-253-5231
  • Fax:
Mailing address:
  • Phone: 217-253-5231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KIRK MOBERG
Title or Position: SENIOR VICE PRESIDENT
Credential: M.D., PH.D.
Phone: 217-337-4105