=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316236573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOMENS HEALTH PRACTICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2011
-----------------------------------------------------
Last Update Date | 06/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2109 S NEIL ST
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61820-7266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-356-3736
-----------------------------------------------------
Fax | 217-953-0885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2109 S NEIL ST
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61820-7266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-356-3736
-----------------------------------------------------
Fax | 217-953-0885
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. SUZANNE TRUPIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 217-356-3736
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 00361763
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------