Healthcare Provider Details

I. General information

NPI: 1053363192
Provider Name (Legal Business Name): CENTRAL ILLINOIS LUNG INTERNIST ASSOCIATES, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 CRAIG RD SUITE 112
SAINT LOUIS MO
63141-7132
US

IV. Provider business mailing address

2300 N EDWARD ST
DECATUR IL
62526-4163
US

V. Phone/Fax

Practice location:
  • Phone: 314-336-0945
  • Fax: 314-336-0949
Mailing address:
  • Phone: 217-876-4200
  • Fax: 217-876-4209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: J STEVEN ARNOLD
Title or Position: PRESIDENT
Credential:
Phone: 314-336-0945