Provider Demographics
NPI:1508824723
Name:CERNOVICH, RICK S (MD)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:S
Last Name:CERNOVICH
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 1:113 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:61361-9752
Mailing Address - Country:US
Mailing Address - Phone:815-454-2811
Mailing Address - Fax:815-454-2832
Practice Address - Street 1:530 PARK AVE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356
Practice Address - Country:US
Practice Address - Phone:815-875-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071681207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360716813Medicaid
IL036071681Medicaid
ILK12367Medicare PIN
IL0360716813Medicaid
IL201325Medicare PIN