Provider Demographics
NPI:1689946022
Name:CARLE FOUNDATION PHYSICIAN SERVICES, LLC
Entity Type:Organization
Organization Name:CARLE FOUNDATION PHYSICIAN SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-326-4677
Mailing Address - Street 1:602 W UNIVERSITY AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT - NCW4
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2530
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:401 N KELLER DR
Practice Address - Street 2:SUITES 3 & 4
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1881
Practice Address - Country:US
Practice Address - Phone:217-347-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5129380004Medicare NSC