Basic Information
| Provider Information | |||||||||
| NPI: | 1518284363 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAUL W. ILES INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 E SUNSHINE ST | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658041819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178811580 | ||||||||
| FaxNumber: | 4178817004 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 E SUNSHINE ST | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658041819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178811580 | ||||||||
| FaxNumber: | 4178817004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2010 | ||||||||
| LastUpdateDate: | 05/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | ILES | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 4178811580 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | PSY. D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 1999140683 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 122501848 | 05 | MO | MEDICAID | 122501848 | 01 | MO | MEDICARE | OTHER |