Basic Information
| Provider Information | |||||||||
| NPI: | 1295099125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANWISYE-MASHELE | ||||||||
| FirstName: | IMANI | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ANWISYE | ||||||||
| OtherFirstName: | IMANI | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1818 E WINDSOR RD | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618029566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172559670 | ||||||||
| FaxNumber: | 2172559724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2012 | ||||||||
| LastUpdateDate: | 02/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2012020598 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036139294 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.