Provider Demographics
NPI:1639399157
Name:THERESE POLO, MD, LLC
Entity Type:Organization
Organization Name:THERESE POLO, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:L
Authorized Official - Last Name:POLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-839-3900
Mailing Address - Street 1:807 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GILLESPIE
Mailing Address - State:IL
Mailing Address - Zip Code:62033-1100
Mailing Address - Country:US
Mailing Address - Phone:217-839-3900
Mailing Address - Fax:217-839-1313
Practice Address - Street 1:807 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GILLESPIE
Practice Address - State:IL
Practice Address - Zip Code:62033-1100
Practice Address - Country:US
Practice Address - Phone:217-839-3900
Practice Address - Fax:217-839-1313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty