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General NPI Number Information
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NPI Number | 1659638401
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Entity Type | Organization
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Legal Business Name | PEDIATRIC PROVIDERS OF DANVILLE, LTD
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Dates
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Enumeration Date | 04/18/2012
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Last Update Date | 07/01/2013
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Provider Practice Location Address
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Address Line | 737 N LOGAN AVE
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City | DANVILLE
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State | IL
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Zip | 61832-4363
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Country | US
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Telephone | 217-442-0433
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Fax | 217-442-0485
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Provider Business Mailing Address
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Address Line | 737 N LOGAN AVE
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City | DANVILLE
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State | IL
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Zip | 61832-4363
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Country | US
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Telephone | 217-442-0433
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Fax | 217-442-0485
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Authorized Official
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Title or Position | PRESIDENT AND MEDICAL DIRECTOR
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Name | DR. HOLLY MAE MAES
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Credential | MD
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Telephone | 217-442-0433
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 036113601
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License Number State | IL
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