Provider Demographics
NPI:1982796850
Name:POWERS, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:POWERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 FORT JESSE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6286
Mailing Address - Country:US
Mailing Address - Phone:309-661-6290
Mailing Address - Fax:309-451-1354
Practice Address - Street 1:2200 FORT JESSE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6286
Practice Address - Country:US
Practice Address - Phone:309-661-6290
Practice Address - Fax:309-451-1354
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H04185Medicare UPIN
IL833100Medicare ID - Type UnspecifiedGROUP #
ILCA2264Medicare ID - Type UnspecifiedRR GROUP #
ILL73838Medicare ID - Type UnspecifiedINDIVIDUAL #