Basic Information
| Provider Information | |||||||||
| NPI: | 1831301282 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROSS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19248 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
| FaxNumber: | 2175257616 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 W ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | MORTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615501802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
| FaxNumber: | 3096766545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2007 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036118871 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036118871 | 05 | IL | MEDICAID |