MEDICARE: DOMINIC CHARLES IMBURGIA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	238531	OTHER	IL	HEALTHLINK
2	40058	OTHER	IL	HEALTH ALLIANCE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	03800063	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1114955960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIC CHARLES IMBURGIA M.D.

Provider Business Mailing Address
First Line	:	901 N MAPLE ST
Second Line	:
City	:	EFFINGHAM
State	:	IL
Zip	:	62401-6401
Country	:	US
Telephone Number	:	217-347-2900
Fax Number	:	217-347-2922

Provider Business Practice Location Address
First Line	:	901 N MAPLE ST
Second Line	:
City	:	EFFINGHAM
State	:	IL
Zip	:	62401-6401
Country	:	US
Telephone Number	:	217-347-2900
Fax Number	:	217-347-2922

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/08/2007

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