Provider Demographics
NPI:1891843595
Name:CENTRAL ILLINOIS ORAL AND MAXILLOFACIAL SURGERY, PC
Entity Type:Organization
Organization Name:CENTRAL ILLINOIS ORAL AND MAXILLOFACIAL SURGERY, PC
Other - Org Name:CENTRAL ILLINOIS ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INS COODINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:1200 NETWORK CENTRE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-4637
Mailing Address - Country:US
Mailing Address - Phone:217-540-5800
Mailing Address - Fax:217-342-2557
Practice Address - Street 1:1200 NETWORK CENTRE DR
Practice Address - Street 2:SUITE B
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-4637
Practice Address - Country:US
Practice Address - Phone:217-540-5800
Practice Address - Fax:217-342-2557
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL ILLINOIS ORAL AND MAXILLOFACIAL SURGERY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-08
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0249421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1014426Medicaid
ILU76781Medicare UPIN