Basic Information
| Provider Information | |||||||||
| NPI: | 1467074138 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARLE WEST PHYSICIAN GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W PARK ST | ||||||||
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| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 2173834752 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 FRANKLIN AVE STE 3400 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617616523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3095568295 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2020 | ||||||||
| LastUpdateDate: | 05/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEONARD | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2173833468 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.