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General NPI Number Information
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NPI Number | 1689751356
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Entity Type | Organization
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Legal Business Name | WESTERN ILLINOIS ENT AND ALLERGY
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 104 W 6TH ST SUITE 303
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City | STREATOR
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State | IL
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Zip | 61364-2899
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Country | US
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Telephone | 815-673-6368
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Fax | 866-262-4460
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Provider Business Mailing Address
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Address Line | 104 W 6TH ST SUITE 303
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City | STREATOR
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State | IL
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Zip | 61364-2899
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Country | US
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Telephone | 815-673-6368
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Fax | 866-262-4460
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHARLES DICKERSON
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Credential | MD
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Telephone | 815-673-6368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207KA0200X
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Taxonomy Name | Allergy Physician
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License Number | 36055109
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 36055109
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License Number State | IL
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