Basic Information
| Provider Information | |||||||||
| NPI: | 1174733521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAVALLO | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627083428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005775368 | ||||||||
| FaxNumber: | 2177572021 | ||||||||
| Practice Location | |||||||||
| Address1: | 3132 OLD JACKSONVILLE RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627047401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175882600 | ||||||||
| FaxNumber: | 2178620904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036041159 | IL | Y | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | 258002 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036-041159 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 036041159 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208600000X | 258002 | NY | N | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.