Basic Information
| Provider Information | |||||||||
| NPI: | 1003375270 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEP AMERICA - ILLINOIS SNF, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CUMMINS DR STE D | ||||||||
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| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953586411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 PERRYMAN ST | ||||||||
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| City: | LEBANON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622541356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185376165 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2019 | ||||||||
| LastUpdateDate: | 03/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | BIRDSALL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5103502600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | 03/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.