Basic Information
| Provider Information | |||||||||
| NPI: | 1689751356 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN ILLINOIS ENT AND ALLERGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 W 6TH ST | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | STREATOR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613642899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156736368 | ||||||||
| FaxNumber: | 8662624460 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 W 6TH ST | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | STREATOR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613642899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156736368 | ||||||||
| FaxNumber: | 8662624460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DICKERSON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8156736368 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | 36055109 | IL | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy | 207Y00000X | 36055109 | IL | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.