Healthcare Provider Details

I. General information

NPI: 1881891471
Provider Name (Legal Business Name): DERRICK E ROLLO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST
URBANA IL
61801-2529
US

IV. Provider business mailing address

611 W PARK ST BWPC
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3311
  • Fax: 217-383-3463
Mailing address:
  • Phone: 217-383-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125-051736
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number02004004A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036122306
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: