=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952427163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CC MEDICAL CLINIC SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 10/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1141 N CHENEY ST
-----------------------------------------------------
City | TAYLORVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62568-2741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-287-7477
-----------------------------------------------------
Fax | 217-287-7511
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1141 N CHENEY ST
-----------------------------------------------------
City | TAYLORVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62568-2741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-287-7477
-----------------------------------------------------
Fax | 217-287-7511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HWA-LONG CHEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 217-287-7477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VX0000X
-----------------------------------------------------
Taxonomy Name | Obstetrics Physician
-----------------------------------------------------
License Number | 036-049201
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------