Provider Demographics
NPI:1659489250
Name:BUCKLEY, WILLIAM R (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:BUCKLEY
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 1:180 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2608
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-649-5302
Practice Address - Street 1:180 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2608
Practice Address - Country:US
Practice Address - Phone:309-647-0201
Practice Address - Fax:309-647-9652
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360851714208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085171OtherOSF HEALTHPLANS
IL222121OtherHEALTH LINK
CG5172OtherRR MEDICARE
IL02922981OtherBCBS
IL0062839OtherUMWA
IL200397OtherBLACK LUNG
IL014155OtherHEALTH ALLIANCE
IL036085171Medicaid
IL1942315197OtherNPI CLINIC NUMBER
ILIL0116OtherJOHN DEERE
CG5172OtherRR MEDICARE
IL222121OtherHEALTH LINK
IL200397OtherBLACK LUNG
ILA01681Medicare UPIN