Provider Demographics
NPI:1477676757
Name:SENIOR HEALTH AND GERIATRICS OF CENTRAL ILLINOIS
Entity Type:Organization
Organization Name:SENIOR HEALTH AND GERIATRICS OF CENTRAL ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:UDAY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEOSKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-663-5810
Mailing Address - Street 1:2103 E. WASHINGTON ST
Mailing Address - Street 2:2C
Mailing Address - City:B LOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4365
Mailing Address - Country:US
Mailing Address - Phone:309-663-5810
Mailing Address - Fax:
Practice Address - Street 1:2103 E. WASHINGTON ST
Practice Address - Street 2:2C
Practice Address - City:B LOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4365
Practice Address - Country:US
Practice Address - Phone:309-663-5810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC45072Medicare UPIN
IL208591Medicare PIN