Healthcare Provider Details

I. General information

NPI: 1528143971
Provider Name (Legal Business Name): RICHARD LEWIS O'HALLORAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 11/27/2023
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 N COUNTY ROAD 700
WARSAW IL
62379-3011
US

IV. Provider business mailing address

927 BROADWAY ST SUITE 303
QUINCY IL
62301-2719
US

V. Phone/Fax

Practice location:
  • Phone: 217-256-4100
  • Fax: 217-222-9807
Mailing address:
  • Phone: 217-223-8400
  • Fax: 217-222-9807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036089108
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: