Basic Information
| Provider Information | |||||||||
| NPI: | 1114970761 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL ILLINOIS PATHOLOGY, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10335 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530925763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622409870 | ||||||||
| FaxNumber: | 2622409869 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 NE GLEN OAK AVE | ||||||||
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| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616370001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096249011 | ||||||||
| FaxNumber: | 3096249152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 10/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3096249011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.