Provider Demographics
NPI:1891787529
Name:DOUGHERTY, ROBERT LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEE
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 E US 40
Mailing Address - Street 2:
Mailing Address - City:CASEY
Mailing Address - State:IL
Mailing Address - Zip Code:62420-3113
Mailing Address - Country:US
Mailing Address - Phone:217-382-4754
Mailing Address - Fax:217-932-5191
Practice Address - Street 1:412 NW 3RD ST
Practice Address - Street 2:
Practice Address - City:CASEY
Practice Address - State:IL
Practice Address - Zip Code:62420-1014
Practice Address - Country:US
Practice Address - Phone:217-932-4061
Practice Address - Fax:217-932-5191
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000498363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL77014Medicare PIN
ILR17263Medicare UPIN