Provider Demographics
NPI:1114955960
Name:IMBURGIA, DOMINIC CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:CHARLES
Last Name:IMBURGIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-6401
Mailing Address - Country:US
Mailing Address - Phone:217-347-2900
Mailing Address - Fax:217-347-2922
Practice Address - Street 1:901 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-6401
Practice Address - Country:US
Practice Address - Phone:217-347-2900
Practice Address - Fax:217-347-2922
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL238531OtherHEALTHLINK
IL40058OtherHEALTH ALLIANCE
IL03664959Medicaid
IL03800063OtherBCBS
IL40058OtherHEALTH ALLIANCE
IL03800063OtherBCBS