=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710701701
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL ILLINOIS RHEUMATOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2024
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11003 N TUSCANY RIDGE CT
-----------------------------------------------------
City | DUNLAP
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61525-7518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-552-7404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11003 N TUSCANY RIDGE CT
-----------------------------------------------------
City | DUNLAP
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61525-7518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-552-7404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HANI HABAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 562-552-7404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------