MEDICARE: CENTRAL ILLINOIS PEDIATRIC ASSOCIATES LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1174706816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL ILLINOIS PEDIATRIC ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	2427 MALONEY DRIVE
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-3750
Country	:	US
Telephone Number	:	309-663-1011
Fax Number	:

Provider Business Practice Location Address
First Line	:	2427 MALONEY DR
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-3750
Country	:	US
Telephone Number	:	309-663-1011
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SANJAY SAXENA
Credential	:	M.D.
Telephone Number	:	309-663-1011

Provider Enumeration Date	:	12/17/2007
Last Update Date	:	12/17/2007

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