Provider Demographics
NPI:1457629842
Name:OTIS ALLEN MD SC
Entity Type:Organization
Organization Name:OTIS ALLEN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-827-3881
Mailing Address - Street 1:1215 HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2214
Mailing Address - Country:US
Mailing Address - Phone:309-827-3881
Mailing Address - Fax:309-661-0234
Practice Address - Street 1:1215 HOLIDAY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2214
Practice Address - Country:US
Practice Address - Phone:309-827-3881
Practice Address - Fax:309-661-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064804208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064804Medicaid
IL036064804Medicaid
IL691890Medicare PIN