Provider Demographics
NPI:1285843011
Name:FLETCHALL, WILLIAM EDMUND (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:EDMUND
Last Name:FLETCHALL
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 1:7501 N VILLA LAKE DR UNIT 9A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8280
Mailing Address - Country:US
Mailing Address - Phone:309-691-5133
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-6710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-049796207P00000X
IL036118956207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361189564Medicaid
ILP00655422OtherRAILROAD MCARE THRU CES
ILP00936448OtherRRMCARE THRU CESIISC (GES)
IL36118956OtherBCBS
IL36118956OtherBCBS
ILR03439Medicare PIN