Provider Demographics
NPI:1952351546
Name:CENTRAL ILLINOIS ALLERGY AND RESPIRATORY
Entity Type:Organization
Organization Name:CENTRAL ILLINOIS ALLERGY AND RESPIRATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENNON
Authorized Official - Middle Name:H
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-522-5596
Mailing Address - Street 1:543 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-4978
Mailing Address - Country:US
Mailing Address - Phone:217-522-5596
Mailing Address - Fax:217-522-5599
Practice Address - Street 1:543 W MILLER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4978
Practice Address - Country:US
Practice Address - Phone:217-522-5596
Practice Address - Fax:217-522-5599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RA0201X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & ImmunologyGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212326Medicare PIN