Provider Demographics
NPI:1568406064
Name:STOMBAUGH, REX (PA)
Entity Type:Individual
Prefix:
First Name:REX
Middle Name:
Last Name:STOMBAUGH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-5613
Mailing Address - Country:US
Mailing Address - Phone:618-532-9050
Mailing Address - Fax:
Practice Address - Street 1:1441 W BROADWAY
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-5613
Practice Address - Country:US
Practice Address - Phone:618-532-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCE9335OtherRR GROUP NUMBER
ILP00345215OtherRR MEDICARE NUMBER
ILCE9335OtherRR GROUP NUMBER