=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104831627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JO ANN ARCHEY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 01/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 W BORMAN DR
-----------------------------------------------------
City | RANTOUL
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61866-3632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-892-9671
-----------------------------------------------------
Fax | 217-892-2530
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 W UNIVERSITY AVE
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61820-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-366-8107
-----------------------------------------------------
Fax | 217-366-6106
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036-110125
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------