Basic Information
Provider Information | |||||||||
NPI: | 1275898116 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DINA | ||||||||
FirstName: | PELE | ||||||||
MiddleName: | BOUTROUS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 19676 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 627949676 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2175458000 | ||||||||
FaxNumber: | 2177576844 | ||||||||
Practice Location | |||||||||
Address1: | 415 N 9TH ST # 4W16 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 62702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2175458000 | ||||||||
FaxNumber: | 2177576844 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2012 | ||||||||
LastUpdateDate: | 05/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 036-138186 | IL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
ID | Type | State | Issuer | Description | 036-138186 | 01 | IL | STATE LICENSE | OTHER |