Provider Demographics
NPI:1184643231
Name:BARTH, DARYL G (CPO)
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:G
Last Name:BARTH
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 W CARPENTER STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4945
Mailing Address - Country:US
Mailing Address - Phone:217-789-1450
Mailing Address - Fax:217-789-1454
Practice Address - Street 1:355 W CARPENTER STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4945
Practice Address - Country:US
Practice Address - Phone:217-789-1450
Practice Address - Fax:217-789-1454
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL361442736001Medicaid