Basic Information
| Provider Information | |||||||||
| NPI: | 1003328329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEP AMERICA - ILLINOIS SNF, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST STE 900 | ||||||||
| Address2: | |||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502680 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4500 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182337750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2017 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | BIRDSALL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5103502680 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.