Provider Demographics
NPI:1619060977
Name:SWINK, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:SWINK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-9786
Mailing Address - Country:US
Mailing Address - Phone:815-664-0605
Mailing Address - Fax:815-664-0507
Practice Address - Street 1:105 S JOHN ST
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420-1413
Practice Address - Country:US
Practice Address - Phone:815-584-3343
Practice Address - Fax:815-584-3647
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104289Medicaid
IL080172564Medicare ID - Type UnspecifiedRR INDIVIDUAL #
IL828130Medicare ID - Type UnspecifiedGROUP #
IL036104289Medicaid
ILL85894Medicare ID - Type UnspecifiedINDIVIDUAL #
G95626Medicare UPIN