MEDICARE: CENTRAL ILLINOIS FAMILY PRACTICE

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	363LF0000X	Family Nurse Practitioner	209003483041	IL

General Provider Information

NPI Number	:	1558665596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL ILLINOIS FAMILY PRACTICE

Provider Business Mailing Address
First Line	:	603 N LOGAN AVE
Second Line	:
City	:	DANVILLE
State	:	IL
Zip	:	61832-4320
Country	:	US
Telephone Number	:	217-213-5254
Fax Number	:	217-213-5240

Provider Business Practice Location Address
First Line	:	603 N LOGAN AVE
Second Line	:
City	:	DANVILLE
State	:	IL
Zip	:	61832-4320
Country	:	US
Telephone Number	:	217-213-5254
Fax Number	:	217-213-5240

Authorized Official
Title or Position	:	FAMILY NURSE PRACTITIONER
Name	:	MR. MICHAEL CURTIS WAGNER II
Credential	:	FNP
Telephone Number	:	217-213-5254

Provider Enumeration Date	:	01/05/2011
Last Update Date	:	01/05/2011

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