Provider Demographics
NPI:1245415199
Name:PAWSON, PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:PAWSON
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 1:402 PINE ST.
Mailing Address - Street 2:PO BOX 135
Mailing Address - City:DELAVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61734
Mailing Address - Country:US
Mailing Address - Phone:309-244-7669
Mailing Address - Fax:
Practice Address - Street 1:402 PINE ST.
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:IL
Practice Address - Zip Code:61734
Practice Address - Country:US
Practice Address - Phone:309-244-7669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119614208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216256Medicare PIN