Basic Information
| Provider Information | |||||||||
| NPI: | 1801907431 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LI | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W PARK ST | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 2173834752 | ||||||||
| Practice Location | |||||||||
| Address1: | 3105 FIELDS SOUTH DR | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618223743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2179027527 | ||||||||
| FaxNumber: | 2179027755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 04/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | 37821 | WI | N | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 2086S0122X | 01065914A | IN | N | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 208200000X | 036129123 | IL | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 34055400 | 05 | WI | MEDICAID | 200928690 | 05 | IN | MEDICAID | 000000596754 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER |