Basic Information
| Provider Information | |||||||||
| NPI: | 1033866801 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARLE WEST PHYSICIAN GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3310 FIELDS SOUTH DR | ||||||||
| Address2: | FAPC | ||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618223741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2179025291 | ||||||||
| FaxNumber: | 2179027711 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 TRINITY LN STE 111 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617048112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096636461 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2022 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEONARD | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2179025291 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE CARLE FOUNDATION | ||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.