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General NPI Number Information
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NPI Number | 1992829485
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Entity Type | Organization
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Legal Business Name | CARDINAL MEDICAL GROUP, LTD.
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6339 N BIG HOLLOW RD
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City | PEORIA
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State | IL
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Zip | 61615-2907
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Country | US
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Telephone | 309-693-3315
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Fax | 309-693-9385
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Provider Business Mailing Address
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Address Line | 6339 N BIG HOLLOW RD
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City | PEORIA
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State | IL
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Zip | 61615-2907
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Country | US
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Telephone | 309-693-3315
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Fax | 309-693-9385
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. MICHAEL A SHADLEY
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Credential |
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Telephone | 309-693-8611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State | IL
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