Provider Demographics
NPI:1992829485
Name:CARDINAL MEDICAL GROUP, LTD.
Entity Type:Organization
Organization Name:CARDINAL MEDICAL GROUP, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-693-8611
Mailing Address - Street 1:6339 N BIG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2907
Mailing Address - Country:US
Mailing Address - Phone:309-693-3315
Mailing Address - Fax:309-693-9385
Practice Address - Street 1:6339 N BIG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2907
Practice Address - Country:US
Practice Address - Phone:309-693-3315
Practice Address - Fax:309-693-9385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty