Healthcare Provider Details

I. General information

NPI: 1972724979
Provider Name (Legal Business Name): KIMBERLY B WHITAKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 TUSCOLA BLVD SBL TUSCOLA CLINIC
TUSCOLA IL
61953
US

IV. Provider business mailing address

1005 HEALTH CENTER DR STE 201
MATTOON IL
61938-4693
US

V. Phone/Fax

Practice location:
  • Phone: 217-253-2020
  • Fax: 217-253-2023
Mailing address:
  • Phone: 217-238-6055
  • Fax: 217-258-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5901
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036125554
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: